Carers4PD

Personality Disorders Empowerment Guide

A Guide For Those Who Meet The Diagnostic Criteria And For Their Family And Friends

Kevin Emry Dennis Lines Carers4PD

1 Introduction

This comprehensive empowerment guide, may help people to overcome some of the difficult relationship dynamics that often arise in connection with Personality Disorders (PD) and are a fundamental part of a Personality Disorder diagnosis, given the fact that; by diagnostic definition; Personality Disorders consist of “inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others,” (DSM IV).

The guide is intended equally for the benefit of people that meet the personality disorder diagnostic criteria and for people that are involved in a close personal relationship with them, partners, parents, siblings, children etc. Although the guide is divided into sections aimed primarily at one or the other of each of those two groups of people it is highly recommended that all users of the guide; irrespective of if they meet the diagnostic criteria themselves or have a close personal relationship with someone else that does; read all sections

People that meet the personality disorder diagnostic criteria will gain immense benefit by looking at things from the perspective of someone that doesn’t meet the diagnostic criteria but cares deeply about someone that does and people that don’t meet the diagnostic criteria but are involved in a close personal relationship with someone that does, will also benefit by reading the section aimed primarily for people that do meet the diagnostic criteria.

Historically, individuals with any sort of mental health problems have automatically been treated as invalids of some kind, someone that needs looking after. The language and structure of mental health services reflects this concept with a “Duty of Care,” “Support Workers,” “Care Pathways,” “Care Plans,” etc. The emphasis is placed firmly on the concept of taking care of, looking after and providing support, invalid care, as opposed to placing the emphasis on the concepts of providing treatment, making well and empowering. It is inevitable that as a result, the relatives of people with a PD diagnosis tend to fall into the trap of treating the individuals concerned as invalids of some kind, assuming responsibility for them and making allowances for their behaviour.This effectively dis-empowers everyone, encourages dependency and reinforces the problems in the long run.

Difficulties Associated with Personality Disorders Some of the most potentially destructive problematic factors associated with a personality disorder diagnosis include: - Limited Affect Control (Difficulty processing and/or containing overwhelming feelings and emotions). Irresponsible Impulsivity, Emotional Dependency, Self-Harm, Suicidality, Substance Misuse, Domestic Violence. All of which potentially entail extremely volatile interpersonal relationships.

Supporting someone with personality disorder can lead to a decline in a carer’s own mental health, personal relationships and employment status (Briggs & Fisher 2000).

Family members often on ‘front line’ serving as case managers and crisis intervention teams , thrust into roles that cause them to feel ill prepared, too traumatised and dis-empowered to be of help to their relative. (Hoffman, Penney and Woodward, 2002)

2 Family members are at high risk of depression and suffer from feelings of burden, grief and isolation (Hoffman, Fruzzetti, Buteau, 2007)

The feelings of being traumatised and dis-empowered together with feelings of burden, grief isolation and depression are also features of many diagnostic categories of Personality Disorder of course. It is widely recognised that the lives of people that meet the criteria for a diagnosable personality disorder often consist of crises after crises. What is usually not recognised or acknowledged, is the fact that if that person happens to be someone that you deeply care about, your son, daughter, parent, sibling, or your partner, your life consists of crises after crises as well. How long can it be before the trauma and stress results in the individual, the “carer,” concerned having some sort of breakdown themselves and the “carer” relationship developing into a co-dependent relationship in which both parties have diagnosable mental health or “stress related” problems of some kind?

This guide is not simply about empowering individuals that meet the Personality Disorder diagnostic criteria. It is also about establishing healthy, collaborative, mutually supportive relationships in which everyone’s needs are met, everyone is validated and everyone is empowered.

Psychological diagnoses are made in five different categories called Axis.

• Axis 1: Clinical Disorders • Common mental illness. Things like schizophrenia, phobias, neurosis, the sort of things that most people think of in relation to mental illness. • • Axis II: Developmental Conditions • Things like Autism, Asperger’s syndrome, Learning Disabilities, Personality Disorders. • • Axis III: General Medical Conditions • Including malfunction of the endocrine system and other physical problems that may affect mental health. Being physically disabled for example. • • Axis IV: Psychosocial and Environmental Problems • Things like bereavement, divorce, redundancy, homelessness, substance use and other life events that can contribute to psychological problems, shock, Post-Traumatic Stress Disorder. • • Axis V: Global Level of Functioning • The individual’s overall level of functioning. Their general ability to look after themselves under normal circumstances.

Personality disorder is an Axis II psychological developmental condition and not an Axis 1 mental illness. It is the way that an individual has become, how they relate to themselves, others and life in general, their view of the world and the way they function within it, not something that keeps going wrong with the way that they function. In order to be given a personality disorder diagnosis the individual has to be at least eighteen years old, cognitively as well as chronologically. In other words, everyone that meets the Personality Disorder diagnostic criteria has full adult capacity.

3 Definitions of Personality Disorders

Enduring patterns of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture is pervasive and inflexible, has an onset in adolescence or early adulthood. International Statistical Classification of Diseases (ICD 10) Deeply ingrained and enduring patterns manifesting themselves as inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others and are developmental conditions which appear in childhood or adolescence and continue into adult life. Diagnostic and Statistical Manual of Mental Disorders (DSM IV)

Personality disorders are divided into three broad classifications that are called Clusters.

Cluster A: Odd/Eccentric: - Cognitive disorders (Psychosis) Cluster B: Dramatic/Flamboyant: - Affective (Mood) disorders Cluster C: Anxious/Fearful: - Anxiety disorders (Neurosis)

Other than problems that have an organic or biological cause, Personality Disorders encompass the full range of psychiatric difficulties.

There are two different diagnostic classification indexes that are used, the European International Statistical Classification of Diseases (ICD 10) and the American Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although they agree entirely on diagnostic definitions ,some of the names of the diagnostic categories differ. In practice an individual might be given a formal diagnosis from either index depending entirely on the preference of the clinician making the diagnosis. The differences are simply in terminology and are as follows.

DSM IV Cluster A Paranoid, Schizoid, Schizotypal Cluster B Antisocial, Borderline, Narcissistic, Histrionic. Cluster C Obsessive-Compulsive, Avoidant, Dependent

ICD 10 Cluster A Paranoid, Schizoid (Schizotypal does not appear in ICD10) Cluster B Dissocial, Emotionally Unstable Impulsive Type, Emotionally Unstable Borderline Type, Histrionic. Cluster C Anankastic, Anxious (Avoidant), Dependant.

Cluster A, the odd or eccentric group are characterised by perceptual distortions although not necessarily delusional in the definitive sense, eccentricity of thought if you like, similar to psychosis.

4 Psychotic symptoms fall into two classifications, the positive symptoms and the negative symptoms. Positive symptoms of psychosis consist of perceptual distortions, delusional perceptions of reality, hearing voices, hallucinations etc. The negative symptoms consist of withdrawal and apathy. There are three diagnostic categories in cluster A. Paranoid, Schizoid and Schizotypal.

Paranoid Personality disorders are pervasive and affect all levels of functioning. Essentially a diagnosable paranoid personality disorder consists of an extreme overwhelming mistrust of others and a pervasive sense of persecution. Schizoid A schizoid personality disorder is characterised by marked detachment. People with a schizoid personality have little or no interest in close personal relationships and/or social interaction with others, they are indifferent. Indifference is not the same thing as rejection by the way. Rejection is itself a strong response or reaction, but indifference consists of a complete lack of reaction or response. Schizoid personalities are emotionally self-reliant to an exceptional degree that can lead to them feeling totally disconnected, which in turn can develop into the feeling that nothing is real. The lack of a sense of reality is not the same thing as having a delusional or distorted sense of reality. If you feel totally disconnected from everyone, and therefore everything that is happening around you, life itself has a tendency to seem about as real and meaningful as something you watch on TV or read about in a book, none of it has any direct connection to you at all and therefore no meaning. Schizotypal Schizotypal personality disorder is regarded as a more extreme form of a schizoid presentation in which indifference to others has developed into dislike or antipathy creating feelings of marked discomfort when interacting with others. People with a diagnosable schizotypal personality disorder are often very superstitious and/or embrace belief systems that are generally regarded as eccentric by the culture they live in. Once known as “schizophrenia of the simple type” schizotypal personality disorder quite often entails a reclusive life-style and apathy such as that generally associated with the negative symptoms of psychosis.

Cluster B the flamboyant or dramatic, group is characterised by marked impulsivity, a lack of concern or awareness of the effect of behaviour on others and erratic mood swings. There are four categories in cluster B, Antisocial, Borderline, Narcissistic, Histrionic.

Antisocial Antisocial personality disorder is characterised not just by lack of concern or awareness of the effect of behaviour on others, but also by disregard for and violation of the rights and needs of others, the lack of empathy and lack of a sense of social obligation - what is usually referred to as a moral conscience. Antisocial personality disorder is not necessarily synonymous with criminality but if they lack a moral conscience and go around totally disregarding and violating the rights of others they are likely to find themselves involved with forensic services at some point. Approximately 75% of men in prison have an Antisocial personality disorder diagnosis. Some people with an Antisocial PD diagnosis are often very highly functioning socially capable individuals, very smooth talking con- men, some are violent and aggressive and others are not. Substance misuse, especially alcohol, is often although by no means always; a feature of an Antisocial personality disorder. As recently as the nineteen sixties, Antisocial Personality Disorder used to be known as "Moral Insanity" and in those days, all the cluster B personality diagnostic catagories would have fallen within that general term

5 Borderline The border that the term “Borderline” refers to is the border between psychosis and neurosis and Borderline personality disorder is characterised by erratic mood swings that are remarkably similar to those states of mind. Freud called it the “As If” personality because it as is if they are psychotic one minute and as if they are neurotic the next. They are neither psychotic nor neurotic however; they are Borderline. Borderline personality disorder is thought to consist primarily of difficulty containing and/or processing overwhelming feelings or emotions, hence extreme sudden mood swings in response to whatever has just happened, or what has just been said. If an individual is unable to contain or process overwhelming feelings in any other way, they either tend to rely on forms of self-medication like street drugs or alcohol or resort to acting out behaviour like self- harm. It is therefore not surprising that substance misuse and self-harm are both common features of a Borderline diagnosis. The full range of eating disorders is also quite often co-morbid (combined) with a Borderline diagnosis. Approximately 75% of women in prison have a Borderline personality disorder diagnosis and in some ways it is regarded as the female equivalent of an Antisocial personality disorder, in the sense that a typical masculine response to overwhelming feelings, is to externalise it and take it out on someone, or something, whilst a typical feminine response is to internalise it, have a good cry and/or take it out on themselves. This view is supported not only by the fact that most men in prison have an Antisocial diagnosis, while most women in prison have a Borderline diagnosis but also by the fact that approximately 70% of people with an Antisocial diagnosis are male and roughly the same amount; seventy percent, of people with a Borderline diagnosis are female. There is also a very high incidence of traumatic childhood experiences with both diagnostic categories. These experiences often include real, or perceived instances of emotional, physical or sexual abuse

Narcissistic Most people are probably familiar with the myth of Narcissus, the guy that fell in love with his own reflection seen in a river. Individuals meeting the criteria for a diagnosable Narcissistic personality disorder often seem like the living embodiment of Narcissus, giving the distinct impression that they think they are absolutely amazingly fantastic, (which they actually do, on a conscious level). Narcissistic PD entails a grandiose sense of self, an inflated sense of your own importance combined with totally unrealistic expectations of reward and/or recognition. Although Narcissists believe in their own innate superiority on a conscious level and convey the impression of being supremely confident; the entire Narcissistic presentation is actually a mask that conceals a very fragile insecure sense of self that demands constant reinforcement and admiration amounting to Ego worship. The trouble is that Narcissists believe in their own propaganda and the difficulty addressing the problem is that every attempt to challenge the protective mask of self-delusion reinforces the Narcissists need to maintain it.

Histrionic In some ways the Histrionic presentation is the female equivalent of Narcissistic PD and while most Narcissists are male, the majority of people with a diagnosable Histrionic personality disorder are female. Flamboyance and drama are fundamental components of a Histrionic Personality Disorder.

6 Practically every situation tends to become a drama and every drama nearly always escalates into a crisis. Essentially, it involves a very insecure sense of self similar to that of the Narcissist but rather than demanding constant admiration and Ego worship for reinforcement, people with a Histrionic personality disorder simply demand constant attention. Unfortunately, they have a marked tendency to go about it in ways that tend to elicit negative attention and/or are so demanding of attention that it eventually elicits a negative response. Histrionic women are often very seductive and although they invariably have very intense relationships they tend to be of short duration, as it is usually the drama of the affair and the attention it brings that is the attraction, rather than the individual concerned. People with a diagnosable Histrionic personality disorder experience life as a drama, or series of dramas, in which they are the star. Histrionic Personality Disorder used to be known as “Hysterical”.

Cluster C the anxious/fearful group are almost the exact opposite of the cluster B group, who are all impulsive high octane adrenaline junkies living very hectic lifestyles and constantly indulging in high risk behaviour like self-harm, substance misuse etc. In contrast the cluster C group are by definition anxious fearful individuals. However diagnostic categories of PD are by no means mutually exclusive, in fact most people usually exhibit personality traits and characteristics from more than one category, so having a cluster C diagnosis does not necessarily mean that an individual might not also self-harm and/or use street drugs or engage in other high risk behaviours. There are three diagnostic categories in the cluster C classification; Obsessive-Compulsive, Avoidant, Dependent.

Obsessive-Compulsive Obsessive-Compulsive personality disorder is characterised by a marked inability to deal with stress and anxiety, or things which cause stress or anxiety like sudden unexpected changes in routine. In order to minimise stress levels people with an Obsessive-Compulsive personality disorder usually seek to control events . This nearly always entails controlling other people and is usually experienced by others as them being cold, intolerant, unreasonably demanding controlling perfectionists, that are almost totally lacking in understanding and empathy.

Avoidant One of the most effective ways to deal with anxiety and stress is to avoid situations that provoke it. If avoidance is your main or only coping mechanism however, it is inevitable that problems never get resolved and escalate to the point at which they become urgent. This generates more stress which you avoid dealing with until your entire life ends up collapsing around you. It can be an extremely debilitating mind-set. In extreme cases people with Avoidant personality disorders that have nothing physically wrong with them at all, will spend years in bed beneath the duvet avoiding life completely. Essentially, an Avoidant personality disorder consists of a huge inferiority complex which leads to the avoidance of all challenges including social situations and interpersonal interactions that might potentially generate feelings of inadequacy.

Dependent As the term suggests; people with a Dependent personality disorder are emotionally clinging and dependent on others. As a result, they have a very powerful need to please and are often compliant to a degree that makes them extremely vulnerable to exploitation. In essence it consists of a very fragile sense of self that requires the reinforcement of a close personal relationship that most people would experience as stiflingly enmeshed.

7 They become swamped by, or lost in, the other. In extreme cases a Dependent personality disorder entails a complete lack of a sense of self and a need for another to tell them how to be, or to do their thinking for them. People with a dependent personality disorder often feel as though they cease to exist when/if they are not involved in an enmeshed relationship with someone else, they have no sense, or at best a very fragile sense, of self on their own. Dependent PD used to be known as “Inadequate Personality Disorder.”

The preceding descriptions are all inevitably sweeping generalisations that capture the essence of each diagnostic category. They are specific personality traits and characteristics that are likely to manifest differently in individual people with the same diagnosis. One size does not fit all and consequently, no two people with the same diagnosis are exactly alike - any more than any two people sharing the same astrological sign are alike – even though they may share particular personality traits and characteristics. Consequently, it is the individual person that has to be treated and not the illness or the diagnostic label. A person is NOT the “personality disorder”.

Diagnostic categories are not mutually exclusive and most people will exhibit traits and characteristics from more than one diagnostic category. People will usually be given a primary diagnosis of one category, sometimes more than one, with marked secondary characteristics of one or two, or more, others.

Personality Disorder Not Otherwise Specified. When the criteria for a specific diagnosis is not met but the features of two or more are present . These in combination cause clinically significant distress or impairment which is designated as a Personality Disorder Not Otherwise Specified.

Dangerous Severe In view of the media coverage it has received any discussion of personality disorders would be incomplete unless it includes the concept of Dangerous Severe PD. Actually, Dangerous Severe is not a diagnostic category as such in itself. There are however some combinations of personality traits and characteristics that can, if they are extreme or severe, produce a state of mind that makes an individual a potential significant risk to the life of others. Potentially dangerous combinations are severe Antisocial co-morbid (combined) with severe Narcissistic, severe Anti-Social co-morbid with severe Paranoid and/or the worst case possible scenario of a combination of all three, severe Antisocial combined with severe Narcissistic and severe Paranoid. The dictator Idi Amin springs to mind as a glaring example of someone with a diagnosable dangerous severe Antisocial Narcissistic Paranoid personality disorder.

Generally, most people with a diagnosable personality disorder are not a risk to anyone but themselves. Statistically any individual is around five times more likely to be seriously harmed or murdered by someone that odoes n t have any history of mental health problems than they are by someone that has.

An understanding of the different diagnostic classifications is essential for a thorough understanding of Personality Disorders but they can be misleading in that they can easily convey the impression that there are several distinct different Personality Disorders, several different types

8 of “illness.” Actually this is not really the case. The reality is that there are several distinct different types of personalities and they can all become disordered. People with similar personalities, disordered or otherwise, tend to perceive, think, feel and relate to others in similar ways.

When an individual’s personal perspective, the way that they “perceive, think feel and particularly relate to others” deviates markedly from the expectations of the individual’s culture, is “pervasive and inflexible” and causes the individual severe distress and/or significantly impairs their ability to function effectively, it constitutes a diagnosable Personality Disorder of some kind.

Personality Adaptations: No one ever fits nice and neatly into nice tidy diagnostic boxes of course. If we want to understand personality disorders an understanding of the different diagnostic classifications is essential; but let’s look at it in another way as well. Below is a series of statements pertaining to an individual that are divided into different sections, under different headings. Most people will probably agree with at least one of the statements in each section but there will be at least one section with which they will agree with all, or nearly all, of the statements. Read through them and choose the one that you think is most like you. You might find that you agree with nearly all of the statements in more than one section.

CREATIVE DAYDREAMER I am, or tend to be a bit of a daydreamer with a vivid imagination and rich fantasy world I can withdraw into. People sometimes find me a bit aloof or quiet especially in social situations. It's important to me to preserve my own space. I'm creative and sometimes thought of as a bit quirky. I do worry about sudden change and I sometimes get very angry or agitated about it. I have been described as difficult to get close to.

ENTHUSIASTIC OVER-REACTOR I am or tend to be a bit excitable and my heart rules my head. I respond to my environment with passion and enthusiasm often leaping from one thing to another and then lose interest. I get bored very easily and crave the company of others to provide the stimulus I need. I'm often perceived as somewhat vain and dramatic and I can react to situations without thinking. While I'm often fun to be with my underlying fear of rejection can cause conflict in relationships.

RESPONSABLE WORKAHOLIC I am or tend to be a bit of a stickler for the rules. I usually need to clarify things before I can accept them. I have a well-developed sense of duty and responsibility and rarely leave a task half done. I get uptight when people don't follow procedures properly and chaotic situations are extremely uncomfortable for me. I need to know someone really well before I relax and show my feelings and I sometimes struggle with spontaneous expression. I don't enjoy playing much.

CHARMING MANIPULATER I am or tend to be quick thinking and very good at finding ways around a problem. I am not comfortable with the confines of regulations and often avoid filling in forms or conforming to procedures. I'm innovative and good at persuading people to come around to my way of thinking, though I can be impulsive and quick to anger if I'm thwarted. Sometimes I'm thought of as a bit selfish as I put what interests me before the needs or views of others.

9 PLAYFUL CRITIC I am, or tend to be an independent thinker and do not take anything at face value. I often question what is being said and play 'devil’s advocate in discussions'. I rarely seek confrontation in a situation but I may use humour to distract or disrupt. While I am often hard working and warm hearted I can be very stubborn and sometimes obstructive because I deeply resent being told what to do. I often blow hot and cold in relationships which can lead to a bit of confusion or conflict and I need time to go away and have a think about things before I come around to someone else’s point of view.

BRILLIANT SCEPTIC I am, or tend to have high expectations of myself and others. I'm pretty competitive and can be critical of shortcomings in others. I am acutely observant and intuitive, with a good eye for detail. I am however very sensitive to even the slightest criticism which can leave me feeling deeply hurt. This makes me a bit defensive at times, especially if I think I'm in the wrong, so I sometimes blame others when things go wrong. I'm intensely loyal and will always be on the lookout for any threat to myself or those close to me. I sometimes come across as being a bit possessive and this can lead to conflict in close relationships.

Each section is obviously an example of different types of personality traits. Many people will have similar personality traits and characteristics as yourself and will have chosen the same section but there are far more differences between you that make you all the unique individuals you are. It’s the same with personality disorders, people with the same diagnosis differ as markedly from each other as everyone else does, even though they share the same basic personality traits and characteristics. The descriptions in each section are taken from the concept of Personality Adaptations formulated by Transactional Analysis (TA). In themselves they are simply examples of fundamental personality traits but in their extreme form they are associated with different PD diagnostic categories as illustrated below.

Personality Style ( Normal range) (Extreme range) = Personality Disorder Brilliant sceptic <------> Paranoid Creative Daydreamer <------> Schizoid Charming manipulator Antisocial Enthusiastic over-reactor Histrionic Responsible workaholic Obsessive/Compulsive Playful critic Passive/Aggressive

Our greatest strengths are also our greatest weaknesses; when or if they become so extreme that they work against us and create distress or incapacitate our ability to function effectively. We can all be too much like the way we are for our own benefit, or to the detriment of others at times. When that tendency becomes predominant and our personality traits and characteristics are so extreme that they work against us, most of the time it constitutes a diagnosable personality disorder. Think of the broad line in the centre as the point of balance. The closer to that line from the left you are the stronger the particular personality traits concerned. As long as you stay on the left of the line you are a healthy effectively functioning brilliant sceptic, creative daydreamer, charming manipulator or whatever. If you cross over to the right of the line your personality traits have now become so extreme that they sabotage your ability to functioning effectively and constitute a diagnosable personality disorder. Just over the line represents a mild personality disorder; way over to the right

10 constitutes a severe one. It follows that an effective psychotherapeutic intervention for personality disorders is not about a cure or reprogramming but about the individual finding balance within themselves so that their basic personality traits and characteristics work in their favour instead of against them. Which results in them becoming empowered so that they can deal with life effectively. The examples in the box above are known as the Pure Types; those below consist of combinations of different types and are known as the Combination Types.

Borderline consists of a combination of Passive /Aggressive and Antisocial (Playful critic and Charming manipulator)

Narcissistic consists of a combination of Paranoid and Antisocial (Brilliant sceptic and Charming manipulator)

Avoidant consists of a combination of Schizoid and Paranoid (Creative Daydreamer and Brilliant sceptic)

Dependent consists of a combination of Schizoid and Passive/Aggressive (Creative Daydreamer and Playful critic)

Schizotypal is an extreme form of Schizoid (Creative Daydreamer)

Incidentally; Passive/Aggressive used to be a diagnostic category but was removed when it became evident that passive aggressive behaviour is actually perfectly normal and simply a normal personality trait for people meeting the criteria for other personality disorder diagnostic categories, as it is for everyone else.

Other definitions of Personality Disorders

A severe disturbance in the character-logical condition and behavioural tendencies of the individual usually involving several areas of the personality and nearly always associated with considerable personal and social disruption. ICD 10

Personality Disorder is a device for attaching scientific prestige associated with health with what are essentially judgements of value. Barbara Wooten 1956

Personality Disorder is a concept like body odour…indubitably affected by constitution and environment, a source of distress to both sufferer and society, yet imbued with ideas of degeneracy so that its possession is also a personal criticism. Peter Tyrer and Brian Ferguson 1998

Deeply ingrained patterns of inappropriate or inadequate behaviour.

11 Compact Oxford English Dictionary

From the date of Barbara Wooten’s famous observation in 1956 it is clear that Personality Disorder has been a controversial diagnosis for over half a century and given the Oxford English Dictionaries definition it is impossible to seriously dispute either her observation or that of Peter Tyrer and Brian Ferguson in 1998. In view of the long standing controversial status of the diagnosis it might be helpful to re-examine the original definitions we looked at from ICD 10 and DSM IV.

“Enduring patterns of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture is pervasive and inflexible, has an onset in adolescence or early adulthood. International Statistical Classification of Diseases (ICD 10)

Deeply ingrained and enduring patterns manifesting themselves as inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others and are developmental conditions which appear in childhood or adolescence and continue into adult life. Diagnostic and Statistical Manual of Mental Disorders (DSM IV)

“Enduring patterns of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture”

“extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others”

The concept of a mental health diagnosis like PD being based more or less entirely on the degree of conformity or lack of conformity to perceived social norms and expectations is controversial in itself, but the problem is further enhanced by the fact that cultural norms and expectations not only vary considerably in different cultures, but from generation to generation, even decade to decade, within each individual culture. Think about it! When Barbara Wooten made her observation in 1956 homosexuality was regarded as a form of criminal Moral Insanity and gay people were imprisoned and/or sectioned and detained under the mental health act, simply because they were gay. In stark contrast; in recent years the Metropolitan Police have been hauled in front of an industrial tribunal for homophobic sexual discrimination. Similarly, back in 1956 an intimate genital body piercing would not only have been regarded as a horrendous form of unbelievably perverse self-mutilation, but also indicative of very severe extreme psychological disturbance. Anyone who was discovered to have one would definitely have been sectioned under the mental health act. These days it is regarded simply as jewellery, body adornment on a par with pierced ears and there is an equal chance of a clinical psychologist, psychiatrist, psychotherapist or psychiatric nurse having one just as their clients do. There is of course an unstated caveat that the degree and/or nature of the deviation from social norms and expectations has to be such as to cause the individual concerned severe distress and/or significantly impair their ability to function effectively. It’s only a problem if it’s a problem. It’s OK to be different as long as it doesn’t cause severe distress or significantly incapacitate the ability to function effectively, or cause distress to others or society in general. Given the fact that cultural norms and expectations vary considerably in different cultures the implications of the diagnosis

12 within what is supposed to be a multi-cultural society are immense and far beyond the scope of this guide to even begin to adequately address. Personality Disorder pervades all levels of functioning and all levels of society; it is an issue that has significant impact in all spectrums of the social arena and concerns educational, social, forensic and mental health services.

Some Facts and Figures

Up to an estimated thirteen percent of the population have a diagnosable Personality Disorder of some kind.

People with a Personality Disorder diagnosis are more likely to develop Axis 1 common mental illnesses than other people.

Research indicates that 66%-97% of people with a Personality Disorder diagnosis have co morbidity with an axis 1 common mental illness or dual diagnosis (e.g. substance use). 66% Dahl 1986 -97% Alnas and Torgenson 1998

All categories of Personality Disorder are prone to develop all types of axis 1 common mental illnesses but research suggests that there seems to be an extra affinity between substance use and the cluster B categories, an extra affinity between Antisocial personalities and alcohol dependency and an affinity between somatoform disorders (physical disorders with a psychological cause) with the cluster C anxious/fearful Personality Disorder grouping.

At any given time up to two thirds of the beds in psychiatric hospitals all over the country are occupied by people with a Personality Disorder diagnosis, in addition to any other mental health problems that they may have.

It is recognised that comorbidity with Personality Disorders significantly impairs the effectiveness of mental health interventions for other comorbid mental health problems. Self-harm and/or suicidality is not always an element of a diagnosable Personality Disorder but can be present in all categories and are more prevalent with some forms of Personality Disorder than others. An estimated 8%-15% of people with a Borderline Personality Disorder diagnosis complete suicide successfully. Personality Disorders can range from mild to severe in all categories.

The Meaning of Diagnosis Things like the Flu and Measles are viruses which are indicated by various discernible symptoms and can be easily verified with a simple blood test to ascertain if it contains the particular virus. Mental health diagnoses are far more complex and much more difficult to ascertain with certainty. An individual describes the way that they feel, their experiences, the things they have difficulty with and the clinician listens and observes their apparent mood and behaviour, all of these are indications of what might be the problem that needs to be addressed and “treated” in some way. It is not an exact science by any means and no one working in mental health in any capacity would ever claim that it is. To a large extent it is a matter of trial and error. Diagnostic labels are useful, convenient ways to describe and organise our thinking about the problems that people encounter. They are mental constructs developed by psychiatrists that change over time, they do not define anyone, only the

13 problems that people meeting particular diagnostic criteria are dealing with. In precisely the same way that the words Flu and/or Measles simply define the virus that an individual has contracted, not the individual themselves. With regard to Personality Disorders, as previously stated, “it is the person that has to be treated, not the illness or diagnostic label. The person is NOT the personality disorder.

Contributing Factors The question that everyone asks is “what causes it?” The answer is that nothing actually causes someone to have a diagnosable personality disorder. It is the way that a person has developed psychologically, the way they relate to life. There are several factors that can contribute to the development of a negative or grandiose sense of self and/or others and negative or unrealistic expectations of life that in combination can result in a particular “way of being” that constitutes a diagnosable personality disorder. Things like childhood neglect and/or emotional, physical or sexual abuse, constant bullying or ridicule are obviously likely to have a profoundly negative effective on an individual’s psychological development but there are many other contributing factors that are not quite so obvious. Many things can convey feelings of insecurity, for example, often over-hearing parental arguments and assuming that their parents are either arguing about them or are on the point of getting divorced is likely to produce a sense of uncertainty about the future leading to fundamental feelings of insecurity.

Script Beliefs Transactional Analysis (TA) incorporates the concepts of the “Life Script” and “Script Beliefs.” The concept is based on the idea that we write the script of the rest of lives, what is going to happen and what our life is going be like, by the time we are six years old. On the face of it, that statement probably seems completely off the wall to most people, but think about it for a moment before you dismiss the idea completely. If every time you show your parents a picture you have drawn, they show enthusiastic interest and always seem interested in what you do, or what you have to say. If you are also popular at school, do well in sports and usually come top of the class academically, you are obviously likely to develop a sense of yourself as a highly functional creative intelligent individual that other people like and find interesting. Your expectation of others will most likely be that they will like you and treat you well and you will no doubt thrive in social situations. On the other hand; if every time you try to show your parents something you’ve done and/or try to talk to them about something they always tell you not to bother them because they’re busy or trying to watch TV or whatever and you are unpopular at school and don’t have any friends, are the person that no one ever wants in their team in the sports lessons and you get beaten up all the time and always come near the bottom of the class academically, you are equally obviously likely to develop a completely different sense of self and completely different expectations of others and of life in general. Either way you have developed a fairly solid sense of yourself, your position in life and how others see you and will interact with you. Those perceptions are so pervasive and so deeply ingrained, so much a part of an individual’s personality, that they are usually not recognised or articulated on a conscious level, they are fundamental, the way a person relates to themselves, others and life in general, not just something they consciously believe in.

Transactional Analysis calls those sorts of fundamental factors “Script Beliefs.” The Schemata of Schema Therapy and Core Beliefs of Cognitive therapies are more or less identical concepts to TA’s Script Beliefs. If at the age of six you already have a sense of the sort of person you are and how

14 other’s see you and will always interact with you, you already have solid expectations of how your life is going to be and your Life Script is all but written; isn’t it? If you feel good about yourself and your expectation is that others will like you and be friendly and helpful; you will probably be a very confident friendly out-going person that functions very well in social situations, in ways that attract people towards you. Conversely, if you see yourself as someone of no significance that other people find boring and uninteresting you will probably anticipate indifference or rejection from others and will most likely avoid social situations and/or reject other people first, generally behave in ways that push people away from you and keep you isolated. In either event your life script becomes a self- generated, self-fulfilling prophecy that comes to pass. Practically everything that happens in your life can influence your sense of self and others, positively or negatively as the case may be. Life scripts are not irrevocably fixed however, major life events; good or bad; can cause people to see things differently and lead to them rewriting their script. A happy confident trusting psychologically well- adjusted out-going twelve- year old son of a successful financially affluent Jewish psychoanalyst living in Hamburg in 1938 would almost certainly have cause to develop a completely different view of themselves, others and their expectations of life and rewrite their life script by 1943 for example. By the same token, if their mother divorced a domineering bullying man and subsequently married a very caring nurturing man that gave the child concerned a lot of positive encouragement and support it is equally likely to have a profoundly positive effect on the child; changing their perception of themselves and others and their expectations of life in general for the better, leading to them rewriting their life script in a positive way. The foundation of the Transactional Analysis psychotherapeutic model is that people can rewrite their life script at any point in time. Personality Disorder consists of: -

“Enduring patterns of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture is pervasive and inflexible, has an onset in adolescence or early adulthood. International Statistical Classification of Diseases (ICD 10)

Deeply ingrained and enduring patterns manifesting themselves as inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others and are developmental conditions which appear in childhood or adolescence and continue into adult life. Diagnostic and Statistical Manual of Mental Disorders (DSM IV)

In other words, unhelpful self-sabotaging life scripts combined with equally unhelpful self- sabotaging behaviour patterns and coping mechanisms.

Attachment Theory Central to personality disorder is the concept of “belongingness” or rather, the lack of it; a sense of not belonging. If the way you relate to others differs markedly from the norms and expectations of your culture you are highly likely to end up feeling constantly misunderstood; isolated and out of place; as though you don’t really belong anywhere. Attachment is defined as an emotional bond to another person. The eminent psychologist, psychiatrist and psychoanalyst Edward John Mostyn Bowlby (1907-1990) became the first attachment theorist with the publication of his work “Attachment and Loss” in 1969. He defined attachment as a "lasting psychological connectedness

15 between human beings." The central concept is that the earliest bonds formed by children with their primary caregivers (usually the mother) have a tremendous impact that continues throughout life. Primary caregivers that are available and responsive to an infant's needs, the knowledge that the caregiver is reliable and dependable, enable the child to develop a sense of security which creates a secure base from which the child can explore the world. An infant’s survival is completely dependent on them having a reliable dependable caregiver to look after them, feed them and attend to all their other needs. The existence of a two- way emotional bond between the primary caregiver and the infant is thought to be an essential feature of nature which ensures the survival of the species, the maternal instinct. Without it most of the human race, and most other animals, would die in infancy.

Some of Bowlby’s theories were subsequently developed by the psychologist Mary Ainsworth who conducted what has become an iconic research study in the 1970’s known as "Strange Situation" which demonstrated the profound effects of attachment on behaviour. The study involved the observation of the behaviour of children between the ages of twelve months and eighteen months old when they were briefly left alone and then reunited with their mothers. Many of the participating mothers had post- natal depression which made it difficult for them to care for the child effectively and develop healthy positive attachments. The behaviour of the children was discreetly observed by researchers at all times, with the mother’s informed consent of course, and consisted of seven stages.

Stage 1 The mother and infant are together but otherwise alone. Stage 2 A stranger who is a research therapist joins them. Stage 3 The mother leaves the infant and the stranger alone for three minutes. Stage 4 The mother returns and the stranger leaves. Stage 5 The mother leaves and the infant is left completely alone for three minutes. Stage 6 The stranger returns. Stage 7 The mother returns three minutes later and the stranger leaves.

Three major attachment styles were observed and identified, secure attachment, ambivalent- insecure attachment, and avoidant-insecure attachment. Main and Solomon replicated the study in 1986 and added a fourth attachment style called disorganised-insecure attachment. Several studies since then support Ainsworth's and Main’s and Solomon’s attachment styles and strongly indicate that attachment styles developed with the primary caregiver in infancy have an enormous impact on interpersonal relationships and behaviours later in life. Children that develop secure attachments as infants tend to develop more self-esteem and better self-reliance, tend to be more independent, perform better in school, have more successful social relationships and experience less depression and anxiety than those that don’t.

Secure Attachment Secure attachment is demonstrated by the infant showing signs of distress when separated from primary caregivers and joy when they return. When the mother leaves the child is upset but feels secure in the knowledge that she will return and obviously feel secure and able to depend on their primary caregivers. When they are frightened; children with secure attachments seek comfort from their mother or primary caregiver as they know that she will provide comforting reassurance.

Ambivalent Attachment

16 Ambivalently attached children usually become very distressed when a parent leaves but are ambivalent, not particularly interested, when they return. An ambivalent attachment style is thought to be indicative of limited maternal availability. The child feels unable to rely on their mother (or primary caregiver) to be there when they need them.

Avoidant Attachment The pattern of infants with an avoidant attachment style is to avoid parents or caregivers and they display no preference between their mother and a complete stranger. It is thought that an avoidant attachment style results from abusive or neglectful caregivers. Children who are punished or pushed away when seeking care or rarely feel as though their needs are being met by their primary caregiver will learn to avoid seeking help.

Disorganised Attachment Disorganised attachment is indicated by a confusing mixture of behaviour and infants with a disorganised attachment style often seem disoriented, dazed, or confused and they may avoid or resist any interaction with the caregiver. It is thought that a disorganised attachment style stems from inconsistent behaviour on the part of caregivers. Parents may sometimes be a source of comfort and support and sometimes punitive or rejecting. The child is unable to accurately predict the parent’s likely response, leading to a sense of confusion resulting in confused disorganised behaviour on the part of the child.

The style of attachment formed with the primary caregiver within the first eighteen months of life is the blueprint for subsequent attachments. Remember that by diagnostic definition personality disorders consist of “Deeply ingrained and enduring patterns manifesting themselves as inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others and are developmental conditions which appear in childhood or adolescence and continue into adult life.” Because an infant develops a potentially problematic insecure attachment style in the first eighteen months of life it doesn’t necessarily mean that the situation is hopeless though, there is still time for a healthy secure attachment to be formed. If an individual fails to form a secure healthy attachment with a primary caregiver by the time they are about six or seven years old however, interpersonal interactions on any level are likely to be difficult and problematic and the chances of them ever being able to form and sustain what most people would regard as a meaningful fulfilling relationship with anyone, is remote, although they might be able to if they are fortunate to be able to engage in an intensive psychotherapeutic programme of some kind.

Reciprocal Roles The concept of reciprocal roles is a component of Cognitive Analytic Therapy (CAT). Relationships are thought of in terms of complimentary opposites or pairs; such as parent and child, teacher and pupil, doctor and patient, victim and rescuer, victim and perpetrator etc. People will usually identify with a particular role which will become their default mode of functioning. For example; someone that meets the diagnostic criteria for Antisocial personality disorder obviously identifies with the perpetrator; whereas someone that meets the criteria for a dependent or avoidant personality disorder identifies with the victim role. Individuals with a Borderline diagnosis who self-harms are

17 both the victim and also the perpetrator of their self-harm and identify with both reciprocal roles. Although people usually identify with a role that is their default “way of being”, the roles are not static or fixed and any of us can fluctuate from one reciprocal role to the other at any time. Victims can also be perpetrators and perpetrators have often been, and sometimes still are, victims. A child being bullied at home, may then bully someone else at school. He/she is both a victim and a perpetrator of bullying. The default role/s that a person identifies with will obviously influence if not actually determine the way that they relate to and interact with others and are obviously significant components of their life scripts. The absence of positive role models, not just the presence of “bad” ones can contribute to the development of a personality disorder. The absence of positive role models doesn’t necessarily mean that people that would make ideal role models are not available. In order to be a role model for someone, it is essential that they form a positive attachment to you and see you as an important figure in their life whose approval is important and whom they want to emulate. You can be the ideal role model figure and do everything you possibly can to be a positive influence in someone’s life, but unless they form a positive healthy attachment with you; you cannot be an effective role model.

Units of Reinforcement Jacob L. Moreno was a psychoanalyst that is chiefly known for his development of a very powerful psychodynamic therapeutic model called Psychodrama and one of the concepts he developed is that of units of positive reinforcement. It’s something that everyone already knows, although its significance is usually overlooked. If a child has a wide circle of aunts, uncles, cousins, parents, siblings, grandparents, teachers and friends from school that all relate to them positively and give them lots of encouragement and support, each of those relationships constitutes a unit of positive reinforcement that contributes to the child’s sense of self-worth and general well-being. So for arguments sake let’s imagine that a particular individual had a circle of twenty people that provided positive reinforcement when they were growing up. Each of those people represents one unit of positive reinforcement so our individual, let’s call him John, has twenty units of positive reinforcement. When at the age of twenty - three, he receives a letter telling him that he didn’t get a job he applied for and the next day an attractive young lady declines his invitation to dinner he can cope with the sense of rejection and/or failure fairly easily as each of those incidents combined only represent two units of negative reinforcement and they are outnumbered with units of positive reinforcement by twenty to one. So John, thanks to having twenty units of positive reinforcement, can take rejection in his stride and cope with most problems that life throws at him fairly well. Another individual that only has three units of positive reinforcement would probably find it much more difficult to deal with not getting a job he applied for and then having his invitation to dinner declined in the same week, as he only has one unit of positive reinforcement to rely on in reserve. The worst case possible scenario of course is an individual that has no units of positive reinforcement at all but several units of negative reinforcement due to constantly feeling criticised and/or belittled when they were growing up. In which case they will probably be lacking in confidence and have immense difficulty dealing with feelings of rejection, abandonment or failure of any kind and will almost certainly meet the diagnostic criteria for a personality disorder of some sort. Difficulty dealing with feelings of abandonment and rejection are very common features of some categories of PD.

Core Emotional Needs

18 Jeffrey Young, the originator of Schema Therapy, identified five core emotional needs which can contribute to the development of a diagnosable personality disorder if they are consistently unmet.

1. Secure attachments to others, which includes a sense of safety, stability, nurturance and acceptance. 2. A sense of autonomy, competence and a sense of identity. 3. Freedom to express valid needs and emotions. 4. Spontaneity and play. 5. Having realistic limits and self-control.

It is important to bear in mind the fact that it is only problematic if these needs are consistently unmet. Learning to cope with less than instantaneous gratification is also fundamental to developing independent adult autonomy, self-reliance and self-control.

Psychoanalytic Considerations Many people that meet the PD diagnostic criteria have been traumatised at some point in their life and one of the psychoanalytic, or psychodynamic, factors involved entails the abreaction (letting go) of past trauma and the feelings attached to it, but that is not the only psychoanalytic consideration. Personality disorder is an Axis II psychological developmental condition and a feature of that is an over reliance on what are known as the primitive, early or immature psychological defence mechanisms that develop early in life, because as what are known as the mature or advanced psychological defence mechanisms that develop later in life, have not usually developed to their full potential. The early “primitive” psychological defence mechanisms that people meeting the diagnostic criteria for PD tend to rely on more than most other people, and which are primary features of a PD diagnosis are explained on the next few pages. They are psychological processes and defence mechanisms that everyone utilises, but people meeting the PD diagnostic criteria tend to rely on them much more than other people and they are usually more extreme.

Splitting Splitting is a term that is nearly always misused, even by clinicians, as something that people with a personality disorder diagnosis do, more or less deliberately, to MH staff teams and other groups of people. However, this is not what the term actually refers to at all. It is a psychoanalytic term that has specific reference to internal psychological processes and psychological defence mechanisms. When a young child starts to make sense of the world around them they begin the process by compartmentalising things into categories of nice and yummy (things like chocolate, ice cream and candy floss) and yucky nasty and horrible (things like school, being smacked and Brussels Sprouts). As they get older, around the age of about six, they start to develop a third filing cabinet of things like chips and roast potatoes that don’t really belong in the really nice and yummy fiing cabinet along with chocolate, ice cream and candy floss but definitely don’t belong in the yucky nasty and horrible filing cabinet along with school, being smacked and Brussels Sprouts either. Instead they are accepted as being OK”. The largest section of most adult’s internal filing cabinets will be the OK classifications, but this is rarely the case for someone with a diagnosable personality disorder. One of the primary features of most personality disorders is a marked tendency to see things in very concrete black and white terms, there are no colours or shades of grey in the PD internal universe. Everything is either this or that, one thing or the other, black or white. That includes other people

19 who are usually perceived as either entirely good nice wholesome yummy beings or completely horrible nasty yucky creatures that don’t really deserve to live and shouldn’t be tolerated. Everything is split into divisions of good or bad in very solid concrete absolute terms.

Because the way that people with PD relate to others is so polarised; the way that other people relate to them tends to be equally polarised as well when they respond to whatever is being directed towards them from the personality disordered individual concerned. Splitting in staff teams, and other groups of people for that matter, occurs when individuals respond to the polarised interactions of the PD client with natural human responses. This usually results in the people that the person with PD regards as nice and yummy liking them immensely and the people that they perceive as yucky and horrible loathing them intensely. Opinion is split within the staff team or social group. The irony is that those people that the individual meeting the PD diagnostic criteria has placed in the yucky nasty horrible filing cabinet, tend to interact with them in ways that conform to their perception of them as yucky nasty horrible creatures, and they are therefore almost invariably proven right about them, from the personality disordered perspective anyway. This fact obviously reinforces their negative perceptions of others and their expectations of life and conforms to and reinforces their life script, which really does eventually become a self-generated self-fulfilling prophecy, Karma, or as it is sometimes referred to, “The law of return.

Mental Health Staff teams working within specialist personality disorder services are obviously fully aware of the phenomenon of course and regard it as a therapeutic opportunity. A difficulty that usually arises with the phenomenon of splitting is that it is practically impossible to say or do something that the person with PD finds disagreeable and retain your status as one of the nice yummy people. Nice yummy people never say or do disagreeable things, only nasty yucky horrible people do that and you can only possibly be one or the other. If you upset someone that meets the PD diagnostic criteria you are usually immediately transferred into the yucky nasty and horrible section of the filing cabinet. As he or she sees it, they have finally realised what “you are really like”. Twenty years of being there for them as their only friend and confidant goes straight out the window, they’ve finally seen through you at last and know what you’re really like now. You might be transferred back into the nice and yummy filing cabinet at some point, but give it time. Splitting is a psychoanalytic term that is inextricably associated with personality disorders as one of the early psychological defence mechanisms that people meeting the personality disorder diagnostic criteria tend to rely on more than most other people. As personality disorders range from mild to severe in all categories, the extent to which people that meet the diagnostic criteria rely on the early defence mechanisms obviously varies, so the way that any given individual with a diagnosable personality disorder sees things and relates to other people might not always be quite as polarised and absolute as the above description of the concept of splitting might imply but; like everything else with PD; it is a question of degree rather than essence.

Projection Projection is another one of the primitive psychological processes that develop early in life. It consists of the projection of aspects of the self onto others. For instance, an individual might be absolutely convinced that the accusation that they always think they’re right and need to have the last word is absolute rubbish and that others cannot ever concede the fact that they’ve lost the argument, or have the guts to back down and admit the fact that they know they’re wrong and he is right. Typical

20 examples are the archetypal frustrated old spinster who is constantly phoning the police because practically every man she ever meets, including the post man, the man next door and the man in the corner shop, look at her “in that way” and she is sure they are planning to rape her, or the closet latent homosexual who is absolutely convinced that everyone else is gay, but he isn’t!

Transference Transference is similar to projection but it is someone else, a previous relationship that is being projected or transferred onto another. So anyone in a position of authority might be experienced as exactly like an individual’s parent or their old school headmaster for example. The transference might be positive or negative depending on the nature of the particular transferential relationship concerned. Sometimes an individual is perceived to be exactly like the original person but you also get a partial transference in which the other person is consciously perceived to be nothing like the original but the relationship feels the same. Without getting too technical it is probably relevant to point out the fact that in order to be regarded as transference, the transferred relationship has to be from the distant past and inconsistent with the reality of the present relationship and/or person concerned. If the relationship being transferred is a fairly recent one or the current individual actually really is exactly like the person in the past it is known as displacement.

Acting Out Acting Out is another term that practically everyone including clinicians usually misunderstand and misuse. It is almost invariably referred to in the context of deliberate attention seeking behaviour but that is not what it actually means at all. It is a psychoanalytic term that is used to describe gestures and other physical behaviour that express a feeling or emotion. Snapping your fingers, slapping your forehead with the palm of your hand or throwing something, slamming a door in anger and/or punching someone are all examples of typical “normal” acting out behaviour. Part of the psychological developmental condition that PD is includes an over-reliance on the primitive psychological defence mechanisms that develop early in life because the advanced psychological coping mechanisms that develop later in life haven’t really developed to any useful extent. Borderline PD in particular is thought to consist primarily of difficulty containing and/or processing overwhelming feelings and emotions; which is why there is a lot of classic archetypal acting out behaviour like self-harm associated with the Borderline diagnosis. As acting it out in some way is the only coping mechanism at the person’s disposal, it is the only way they can deal with powerful overwhelming feelings and emotions. People can and do learn other more effective coping strategies however, which in itself develops and reinforces the advanced or mature psychological processes that other people use to contain and process feelings and emotions. Learning how to self-soothe and practicing other effective coping skills causes the advanced psychological processes and defence mechanisms, things like empathy identification and sublimation, to develop to their full potential.

There isn’t a single cause of personality disorders but all the factors described can contribute to their development. Personality Disorders are considered to be similar to Post Traumatic Stress Disorder (PTSD) in many ways although they usually constitute adaptations to continual pressures in early life, rather than being a reaction to a single traumatising event.

Emotional, physical and/or sexual abuse are often common factors in the aetiology (development) of Personality Disorders, (as high as 87%-91% in some research studies) and things like school bullying

21 and/or other peer group pressures can also be contributing factors. Anxious over protective parenting can sometimes contribute to excessive emotional dependency and/or other Personality Disorders. Lack of positive role model attachments, not just the presence of bad ones, can also contribute.

Neglect (total lack of boundaries) is thought to be the most damaging factor and chaotic households in which there are a succession of transient neglectful “parental” figures, even though they may not be overtly abusive, is usually regarded as more traumatising than the experience of strict traditional discipline and/or sexual abuse by permanent parental figures within what is otherwise experienced as a caring loving relationship. It is perhaps pertinent to point out that neglect doesn’t necessarily coincide with abuse or deprivation. The worst case scenario is obviously when you get all five, deprivation, neglect, emotional, physical and sexual abuse but a complete lack of boundaries can occur in affluent households in which every material need is met but the child has no firm rules or boundaries regarding their behaviour and every demand is given in to because it is always easier to give in than argue. The result in diagnostic terms is exactly the same.

A question that is often asked is “why is it that one child in a family will develop a personality disorder but none of their siblings have any problems at all, even though they all grew up in exactly the same environment and went to the same school?” The answer is that there are many different reasons. Firstly, no two people can possibly always have identical experiences. Because one child is bullied at school it doesn’t necessarily mean that all their siblings were as well. Perhaps one child doesn’t do as well academically as the others, perhaps one is bullied by another sibling, there are an infinite number of possible variations. The death of a grandparent might not have much of an effect on one child but could have a devastating effect on one of their siblings. Something might happen that a ten- year old can take in their stride but a seven-year old might have immense difficulty dealing with. In addition; everyone is born with a given set of basic personality traits and characteristics, each child is different and while one might deal with things in ways which develop into a diagnosable personality disorder another sibling might deal with them differently. Personality Disorders are thought to develop through a combination of an inherent psychological predisposition leading to maladaptive responses to stressful environmental circumstances. Some people will develop a Personality Disorder in response to specific pressures that other people will deal with differently.

Neurological Considerations Although this guide is not a clinical treatise by any means; this section would probably be incomplete without some reference to neurological considerations in relation to personality disorders and they need to be included, even if only to dispel any ideas that PD has something to do with brain dysfunction. It doesn’t; but something in the region of twenty- five years or more of extensive neurological research has revealed some very interesting neurological processes in connection with PD. Significant neurological similarities have been found to exist between people with Antisocial diagnoses, Borderline diagnoses, people that were sexually abused in childhood, adult victims of sexual abuse and others with a diagnosis of Post- Traumatic Stress Disorder. Neuroimaging reveals underactivity in the orbitofrontal cortex and in the temporal cortex, which are both parts of the brain’s empathy circuit, and the hippocampus; a part of the brain that deals with threat, anxiety and stress, is reduced in size.

22 “Given the association with neglect and abuse in childhood, there is evidence that early stress affects how well the hippocampus functions and how active the neural systems are that respond to threat. Prolonged exposure to stress isn’t good for your brain. The amygdala is one of the brain regions that responds to stress or threat. When it does; it triggers the hypothalamus to trigger the pituitary gland to release a hormone called ACTH (Adrenorcorticotropic hormone). This is then carried by the blood from the brain down to the adrenal gland where it triggers the release of another hormone, Cortisol. Cortisol is often called “the stress hormone” because it is a good indicator of when an animal is under stress. There are receptors for Cortisol in the hippocampus that allow the animal to regulate the stress response. Remarkably too much stress can damage and shrink your hippocampus.” Simon Baron-Cohen Prof: of Psychology and Psychiatry Cambridge University

Trauma and stress reduces the size of the hippocampus, part of the brain that deals with feelings of threat anxiety and stress, so the ability to deal with anxiety and stress effectively decreases; which results in more stress that again reduces the size of the hippocampus, ad infinitum. The good news however is that the process is not irreversible. People have been given neurological scans when entering long term intensive psychotherapy services and again at the completion of therapy. On entering the programmes there was found to be reduced activity in the empathy circuit and the hippocampus was found to be reduced in size as anticipated, but it had grown back to normal proportions and the empathy circuit was fully functional at completion of therapy. Traumatic and/or stressful life events affect the brains physical structure (anatomy) and functional organization (physiology) and so do positive life events, like the experience of being part of a supportive empowering therapeutic community which has an Integrative therapeutic model that incorporates a psychodynamic component; leading to the abreaction (the release or letting go) of trauma. Trauma and stress reduces the size of the hippocampus and positive empowering experiences and learning new effective coping strategies causes it to increase in size again, which in itself empowers the individual concerned to deal with stress more effectively.

There is a great deal to be said in favour of a simple peaceful stress free life style.

“Therapy is just another way of creating synaptic potentiation in brain pathways that control the Amygdala. The Amygdala’s emotional memories, as we’ve seen, are indelibly burned into its circuits. The best we can hope to do is to regulate their expression. And the way we do this is by getting the Cortex to control the Amygdala”

Joseph E LeDoux 1996 Prof: of neuroscience and psychology NY University

There isn’t a single personality or behavioural trait or characteristic associated with personality disorders that isn’t perfectly normal in itself, but they are very extreme. Personality Disorders are extreme versions of normalcy.

Part Two.

23 How can I empower myself if I meet the PD diagnostic criteria?

If you are reading this guide and asking yourself the question above, you have already taken the first essential step towards becoming empowered. The first step is recognising the fact that you are the only person that actually has the power and responsibility to deal with whatever problems you are facing, rather than relying on a doctor or other professional to “make you better” or expecting others to look after you and making it everyone else’s responsibility. You are the only person that can change things. You have to do it yourself, because you really are the only person that has enough influence over your life to do so.

The process of psychotherapy is likewise a process that each individual has to undertake for themselves, it isn’t something that can be done “to” someone or on someone’s behalf. Each individual does their own psychotherapy, the role of the therapist is simply to guide the process and support them on the psychotherapeutic journey. This section of the guide presents a range of concepts and suggestions that are derived from a wide range of psychotherapeutic models and as such, constitute a comprehensive overview of those that an individual engaged in an intensive specialist Personality Disorder Integrative psychotherapeutic programme is likely to encounter. If you are lucky enough to live in an area in which there is an intensive specialist PD psychotherapy service, we would strongly advise you to do everything you can to engage with it. This guide is presented as the next best thing, not as a replacement for psychotherapy. As the psychotherapeutic journey is something which each individual has to do for themselves however, as the next best thing to an intensive psychotherapy program, this guide aims to empower people to undertake their own therapeutic journey, albeit without the benefit of a psychotherapist to provide ongoing guidance and support. Given the somewhat sparse nature of specialist PD psychotherapy services at the present time, it should prove to be of immense benefit to many. For the guide to be effective it is essential that the individual engages with the process and asks themselves the relevant questions and follows the suggestions that apply to their situation. Exactly the same applies with regard to engaging with a psychotherapeutic programme of any kind. As there are ten different diagnostic categories of PD that entail extremes at both ends of the spectrum, it should go without saying that it is inevitable that this section contains many generalisations and some of the contents of this section might not be applicable to everyone that reads it. Each individual needs to bear that in mind and take on board just those that are.

Most people with a personality disorder diagnosis usually experience life as something that happens, or a series of events that keep happening to them, with very little or no sense at all of having any real control of their life. Instead it is usually experienced as simply being blown about by life events, somewhat like a leaf in the wind or bouncing along from one crisis or one disastrous relationship to another like a ball-bearing in a pinball machine. The concept of empowerment entails taking control, climbing into the driving seat and going in the direction you consciously choose to go. Which necessitates being proactive and making the necessary changes to make your life the way you want it to be. That usually means that you have to begin by changing things about yourself and/or the way you do things. Not so much reinventing yourself, as becoming the person you actually already are deep down inside beneath the trauma, negative imprinting, insecure attachment styles, self-

24 sabotaging behaviour patterns, ineffective coping skills and all the rest of it. This guide aims to provide insight, understanding and a range of useful concepts and skills that can empower people to climb into the driving seat and gain control of their life and steer it in the direction they consciously choose to go.

Staying with the driving allegory for a moment, having someone that is willing to drive you around to wherever you want to go like a free taxi service is great but it keeps you dependent on their willingness and availability - dependent on them. In order to be empowered to become independent in that regard you have to climb into the driver’s seat and learn how to steer the car, coordinate the pedals and the gear stick, learn the Highway Code and ultimately pass your driving test and get a driving licence. Then buy a vehicle of your own of course. Someone else can teach you to drive but no one else can learn how to drive and pass the driving test for you, it’s something that you have to do yourself because you are the only person that can. Any given individual is unable to drive a car until they learn how to but the vastly overwhelming majority of people have the capacity to learn to drive. It’s exactly the same with other life skills and everyone that meets the criteria for a diagnosable personality disorder has full adult capacity. Because you might be unable to do something at the moment it doesn’t necessarily mean that you can’t, or can’t learn how to. Becoming empowered is all about doing something different, learning new skills and making changes, which is a very scary challenging idea in itself for people that meet the diagnostic criteria for some categories of personality disorder. It is a very challenging process for everyone and definitely isn’t easy by any means, but the rewards are well worth the effort. The alternative easy option is to stay exactly as you are and your life continuing exactly as it is at the moment, but if you are bothering to read this guide and asking yourself the question above, we assume that you have already come to the conclusion that that simply isn’t a viable option anymore. One thing is absolutely certain; if you continue doing exactly what you’ve always done you are always going to get exactly what you’ve always had and nothing is ever going to change.

Reflection One of the author Mark Twain’s famous observations is to the effect that “the unexamined life is a life not lived.” Back in the olden days when I was a lad, as they say, a diary consisted of a book of blank, or occasionally lined, pages that was at least the size and thickness of the average paper back and was intended to be used as a reflective journal, a place in which to record daily thoughts and events. This obviously tended to help develop the capacity for reflection. Today what is called a diary usually consists of dated pages that are often actually sub divided into different times by the hour or half hour and are actually only appointment and address books, not real diaries as such at all. We live in a culture in which the practice of reflection is becoming increasingly devalued and increasingly rare. One of the features of some categories of personality disorder is reckless impulsivity, the tendency to act without stopping to pause and reflect on the potential consequences of the action and/or the possible effect on others. It seems a bit odd when we consider that professional visitors to specialist personality disorder psychotherapy services always comment on the exceptionally high standard of the capacity for reflection exhibited by the people engaged in therapy groups. The psychotherapeutic process essentially consists of a process of reflection in fact. People that meet the PD diagnostic criteria have the capacity to be reflective but it is a process that many don’t usually engage in to any worthwhile or useful extent. Another name for the practice of reflection is Mentalisation. Mentalisation Based Therapy (MBT) aims specifically to develop that skill. There are

25 two primary aspects to Mentalisation, self-reflection and other-reflection. Self-reflection, also called metacognition and/or second order thoughts, entails thinking about what you’re thinking and feeling. It questions your assumptions and the logical processes that have led you to form certain conclusions, it re-examines your thoughts and thought processes and re-evaluates their validity, by getting in touch with and naming your feelings. Other reflection is about imagining yourself in the position of another person and thinking about how things probably seem from their perspective and how your actions are likely to affect them, make them feel, and how you, and therefore probably they, would be most likely to feel and respond if your relative positions were reversed. Which obviously tends to encourage feelings of empathy and identification; which in turn stimulates activity in the orbitofrontal cortex and in the temporal cortex, parts of the brain’s empathy circuit. Mentalisation will gradually develop the mature or advanced psychological processes of empathy and identification to their full potential.

If you have read the preceding pages you are aware that PD consists of extreme examples of normalcy at both ends of the spectrum. On the one hand you have Schizoid, Schizotypal and Avoidant personalities that have little or nothing to do with other people at all if they can possibly avoid it and on the other you have Narcissistic, Histrionic and Dependent personalities that rely on constant admiration, constant attention or emotional enmeshment with another person. Recklessly impulsive cluster B types living very high risk lifestyles and regularly engaging in dangerous and sometimes potentially life threatening behaviours at one end of the spectrum and anxious, fearful, cautious cluster C types at the other. So whatever statement or observation applies to people whose personality disorder diagnosis places them at one end of the diagnostic spectrum, is exactly the opposite that which applies to people with a personality disorder diagnosis that places them at the other end of the spectrum. The process of empowerment consists of a process of self-reflection that begins with asking yourself the question, “At which end of the spectrum am I?” Bear in mind the fact that no one fits exactly into nice tidy diagnostic categories but usually have overlapping traits and characteristics from several and that personality disorder diagnosis range from mild to severe in all categories.

There is no single “right” way to be. Some people are more self-reliant than others and some are more or less well organised than most other people. The process of empowerment entails finding a balance within yourself that enables you to deal with life more or less effectively, which in this context means as effectively as most people, and thus feel some sense of contentment and fulfilment. To a greater or lesser extent, this usually involves some changes in lifestyle. If you are a boisterous out-going cluster B type party animal; you will probably benefit by reducing the level of socialising and/or psychoactive substances, you may be indulging in. If you are a reclusive Schizoid or Avoidant sort of person; getting out this weekend and partying will be a change of pace that will probably do you the world of good and developing a more active social life will probably have many long term benefits. Within the realm of personality disorders; what is good for the goose is by no means necessarily always good for the gander. Reflect on your life to date, what are the steps that have led up to and created your present set of circumstances? To some extent other people and external events will have contributed, but so have you. Recognition of that fact is really the first step towards the acceptance of self-responsibility. In order to learn from the past and not constantly repeat the same mistakes it is necessary to reflect and gain awareness of what has led to a particular given situation and the part that you have played in it. The next step is to make a point of not

26 repeating the same behaviour pattern in future. What is your life script? Does it need to be rewritten? Do you have a realistic positive sense of self and others or have you written a tragedy with yourself as the victim? What is your attachment style? Do people know where they stand with you or are you a bit ambivalent in your relationships, leaving people feeling uncertain, confused and insecure? Avoidant perhaps and keeping yourself aloof and isolated? Maybe you’re a bit clingy and needy which pushes people away from you and keeps you alone? Do others consider you as too demanding of attention? Are you the sort of person that feels a need to control others and feel insecure when you can’t perhaps? Are you a tolerant person that thinks other people have as much right to be who they are and “where they’re at” as you do, or do you tend to be intolerant, critical and judgemental? Or are you the sort of person that is too easy going; which results in you constantly being taken advantage of and letting people walk all over you? What is your style of communication like? Do other people find you friendly and confident or over-bearing and antagonistic? Or perhaps you present yourself to others as someone that is meek, mild-mannered and self-effacing? If you haven’t already come to any definite conclusions, re-read the descriptions of the diagnostic categories and the personality styles in the Personality Adaptations exercise. Which ones apply to you and what secondary characteristics do you have and from which other diagnostic categories? Which of the contributing factors do you think apply in your case? The process of empowerment, therapy, begins by reflecting on these sorts of questions and being brutally honest with yourself. Once you know what the answers are, you will know exactly what therapeutic issues you need to address. It might be helpful to actually write the story of your life to date, detailing key events and the way they have affected you or continue to exert an influence on you and the way you feel and relate to and interact with other people today. You might also find it helpful to take up the practice of writing a diary or reflective journal in which to record your thoughts and keep a record of events. Doing so will be a daily reflective exercise that will enhance your ability to clarify and focus your thought processes and strengthen your Mentalisation skills.

Pathologising If someone has a diagnosable personality disorder or any other mental health problems and they wake up in the morning feeling like crap; the natural tendency is to attribute it to their mental health problems. Guess what though, every single person on this planet has days when they wake up feeling like crap and things like anger, anxiety, sadness, depression, even despair are normal human feelings and emotions, not an illness or a psychological disorder. They are not something that needs to be fixed or medicated; just normal responses to life and having to deal with them is a normal part of life. Some people have more effective coping skills than others and find it easier to deal with difficult feelings and/or events and some people are more sensitive than others and experience feelings of stress, anxiety or anger in response to things that don’t really provoke much of any sort of reaction at all in most people; but the feelings themselves are perfectly normal, if sometimes a bit extreme and out of all proportion to the situation perhaps. With some diagnostic categories of PD there is often a distinct tendency, on the part of the individual concerned, to assume that they are the only person on the planet that has to deal with difficult feelings and emotions and to regard them as a symptom of their “mental health problems,” combined with the expectation that therefore everyone else should happily accept their moods and be sympathetic and supportive towards them; irrespective of the reasonableness or otherwise of their behaviour towards everyone else. Lack of motivation is another common feature of some personality disorders and many people that don’t have a diagnosable personality disorder or any other sort of mental health diagnosis also find it

27 immensely difficult to motivate themselves sometimes. Absolutely everything associated with any personality disorder diagnostic category is perfectly normal in itself, it is only the degree; the extent of it that is comparatively unusual. More correctly; it is the individual’s limited ability to deal with it effectively which actually differs markedly from the norms and expectations of an individual’s culture and constitutes the problem.

If you recognise the fact that you have a tendency to place all your problems into a special “symptom of my PD that I can’t do anything about” category; the next step in the empowerment programme is to stop pathologising everything and recognise the fact that even if it is part of something that has a diagnostic label, it is still all actually simply a matter of dealing with life and whatever it throws at you. In that fundamental respect you are exactly the same as everyone else, assuming of course that you do tend to pathologise everything. We are not suggesting that everyone that meets the PD diagnostic criteria will pathologise everything for a moment; only that some people do and that it is very unhelpful and makes it extremely unlikely that they will ever be able to overcome their problems if they do. Life can be full of challenges and is difficult at times for just about everyone. That statement should not be regarded asdisparaging or dismissing of the difficulties that people meeting the criteria for a diagnosable personality disorder encounter. It is simply reframing them, looking at them from a more helpful perspective. The point is that if you see everything as some sort of symptom that you have no control over, it places it into a box that makes it beyond your ability to remedy. It’s a very convenient and terrific excuse, or a dangerous trap, for keeping people stuck exactly as they are. If on the other hand they want to make a genuine attempt to deal with and overcome their problems, one of the things that needs to be done is for them to stop pathologising everything and start looking at things from a more helpful perspective, that can empower them to deal with their problems more effectively. Thinking about things in terms of rewriting the life script or as difficulties encountered on the journey through life that need to be dealt with and overcome, is far more helpful and empowering than thinking in terms of pathology and diagnostic labels. There are of course things like post- natal depression and psychotic episodes that arise from hormonal imbalances or are due to neurological factors but they are not necessarily symptomatic of personality disorder, although there might be comorbidity in some cases. What we are referring to are simply normal human feelings and emotions which might be extreme; disproportionate or inappropriate in some cases; but are not actually a medical condition or a clinical symptom as such. Personality Disorders are Axis II psychological developmental conditions, not Axis I mental illnesses. Learning to regulate feelings and emotional responses effectively is obviously a fundamental part of becoming empowered for anyone that has difficulty in that regard. As personality disorders consist of extremes at both ends of the spectrum it should go without saying that for some categories of personality disorder, the difficulty is not so much a matter of regulating emotional responses, as one of getting in touch with them and feeling anything at all on an emotional level. Continuing the reflective process, think about what aspects of yourself and your problems are actually something to do with mental health and what aspects have far more to do with difficulty coping and dealing with difficult feelings, life or life events reasonably effectively?

The OK Corral The OK Corral is another concept of Transactional Analysis and illustrates the ways in which people relate to themselves and others on a spectrum of “I’m OK or I’m not OK and You’re OK or You’re not

28 OK.” The “you or you’re” in this context refers to people in general; rather than any specific individual. For the purposes of the OK Corral the concept of “I’m OK” signifies having a realistic positive sense of self as someone that is a reasonable and effectively functioning person that might never win an Olympic medal or the Nobel prize but doesn’t need to; because they are basically OK as they are. The concept of “You’re OK” signifies having a perception of other people as basically OK if you give them the chance, with as much right to be who they are and “where they’re at” as you, even if you may not have a lot in common with each other. There are a number of ways in which other people might be perceived as not OK but they basically all boil down to them either being seen as unreliable, untrustworthy, threatening in some way, need help or as defective or inferior in some way.

You’re OK

Position 4 Position 1 You’re OK, I’m NOT OK You’re OK, I’m OK

Depressive Healthy

I’m NOT OK I’m OK

Position 3 Position 2 I’m NOT OK, you’re NOT OK I’m OK, You’re NOT OK

Futility Paranoid

You’re NOT OK

Position 1: “I’m OK, You’re OK,” is the healthy position and someone that relates in this way has a realistic positive optimistic view of themselves and others and is basically psychologically well adjusted. It doesn’t mean that they are naive, they read the papers just like everyone else and are fully aware that crimes are committed by some people and there are crooked politicians etc. but they give everyone the benefit of the doubt and assume they are honest and basically OK, even though they may not have much in common with them, unless they do something that suggests otherwise. Position 2: “I’m OK, You’re not OK,” is known as the Paranoid position and people in this position feel mistrustful or threatened by others in some way; which usually provokes a desire to get rid of them, reject them. Position 3: “I’m not OK and you’re not OK either,” again incorporates a sense of mistrust of others or the feeling that other people can’t be relied on; combined with a negative self-image and is the position of futility, the sense that everything is hopeless and it isn’t even worth making the effort, which also tends to lead to the rejection of other people. Position 4: “You’re OK, I’m not OK,”

29 obviously entails a negative self-image and is known as the Depressive position and entails either the desire to get away from (reject) others; or to find a rescuer.

Everyone will experience temporary moments when they have a negative view of themselves or others, when they forget something important or feel they have let themselves or someone else down or when they are stuck in a traffic jam or their plain or train is delayed for example, but everyone has a primary position that constitutes the way they usually relate to themselves and other people. This is their basic fundamental default mode of functioning. These perceptions of self and others are script beliefs that are fundamental to an individual’s life script and constitute the foundation of their personality. If I am in Position 1: - the “I’m OK, you’re OK“ position, I am an open trusting friendly person with a secure realistic positive sense of self and a positive optimistic view of people in general. If I am in Position 2: - the “I’m OK, You’re not OK” position, I am mistrustful and rejecting of others, possibly antagonistic, aggressive, maybe even threatening, or I may be fearful and full of anxieties and may also actually have an unrealistic overinflated opinion of myself. Either way I have a completely different personality than I would have if I was in Position 1: – the “I’m OK, you’re OK position” and am someone else entirely. It is the same with all the positions on the OK Corral, the foundation of everyone’s personality is how they relate to themselves and others, i.e. their position in the OK Corral. It is therefore also the foundation of a diagnosable personality disorder of course. The next obvious question to be asked is, “Where do you usually stand in the OK Corral?” Remember that you can move around it and stand somewhere else; if you choose to do so. Which entails re-evaluating the way you relate to yourself and to other people in general. Momentary reflection on the concept of Life Scripts and a perusal of the Contributing Factors section of this guide should prove helpful in this regard.

The Four Passive Behaviours The four passive behaviours are ineffective self-sabotaging modes of functioning that discount the ability of the self to solve problems and deal with things effectively and are sometimes physically harmful to the self or others.

Doing nothing Doing nothing is a fairly common response to a wide range of situations; typical simple examples are things like just standing or sitting still looking sullen or blankly staring. The person concerned seems to freeze like a rabbit caught in headlights and does absolutely nothing, totally discounting any ability to deal with the situation and experiencing themselves as having a mental blank and not thinking at all. It never occurs to them that they can be proactive and say or do something about whatever is happening. It can also be a much broader more pervasive behaviour pattern as well however, that results in nothing ever being dealt with. Problems are simply ignored, bills remain unpaid, letters do not get replied to and eventually what were originally simple problems that could easily have been dealt with effectively by making a simple phone call, writing a letter or sending an email develop into large pressing problems that are also ignored and the ultimate result is that all those problems become more extreme and urgent until everything goes wrong at once and the individual’s life falls apart completely and collapses around them.

Over-adaptation

30 The over-adaptation behaviour pattern ultimately stems from a need to please that causes the individual concerned to constantly behave in ways that they think other people expect. People with an ingrained over-adaptation behaviour pattern often seem to be very capable highly functioning accommodating people but they function automatically, without ever checking to ask others if they particularly want or expect them to always do whatever they are doing; or pausing to ask themselves if they actually want to do it or not. They simply perform assorted tasks, fulfil the functions they assume others expect them to, on automatic pilot; although they usually have the illusion that they are thinking. The result is that they tend to be taken for granted, as other people take it for granted that they will do everything, and their own needs are rarely expressed and therefore usually go unmet. That can often become a source of resentment that is rarely; if ever; voiced. The person has totally discounted their ability to act on their own initiative and simply does what they believe others want them to do without even thinking to check it out with them. They do not even ask themselves what they actually want, nor do they at all recognise the fact that they also have needs that also need to be. They discount themselves completely; their unrecognised needs are never articulated and therefore never met.

Agitation Simple examples of agitation are things like tapping your fingers or your foot, biting your nails, twiddling or pulling your hair, thumb sucking, pacing, compulsive eating and/or other compulsive behaviours. Once again the person’s ability to do anything constructive is totally discounted and all their energy is channelled into the completely pointless agitated behaviour. They are automatic actions that people indulge in without thought; usually accompanied by a sense of not thinking or even realising they are engaging in the agitated behaviour. Hair pulling and compulsive eating are obviously both forms of self-harm, if the comfort eating is excessive, and the other forms of agitation behaviours are self-defeating ineffective ways of actually dealing with anything at all constructively. In fact, they are not actually dealing with anything at all but simply pulling their lip or their earlobes or whatever all day instead. Such forms of agitation are simply a subtle form of avoidance.

Escalation Agitation often escalates and turns into, as the term suggests; Escalation. Situations develop into dramas and dramas escalate into crises. Escalation does not necessarily have to be preceded by agitation however; it can also often seem to arise spontaneously. Typical examples include resorting to the use of drugs and/or alcohol and psychosomatic illness, becoming incapacitated in some way and/or externalised violence. All of which are harmful to the self or others and result in problems escalating and becoming worse; rather than being dealt with effectively. Becoming incapacitated, being sick or unwell in some way, allows the individual to assume the passive dependent role of patient, leaving it to someone else to deal with everything, which often results in nothing be dealt with at all. It probably seems strange to think of externalised violence as a passive behaviour but it is passive in the sense that the energy is not directed towards dealing with the issue constructively but into the escalated and ultimately completely pointless destructive violent behaviour instead. Again the individual totally discounts their ability to deal with the problem constructively. Escalation is typical of “acting out” behaviours like deliberate self-harm and/or causing damage to inanimate objects such as smashing the furniture.

31 Passive behaviour patterns of this type usually take time to develop and become ingrained automatic responses that are often instantaneous. They are maladaptive behaviours that usually originate in childhood and were effective coping strategies at the time but are inappropriate and ineffective in adulthood. Being excessively accommodating and doing everything you thought might please your parents (over-adaptation) might have kept you out of trouble and saved your skin a few times and/or given you a sense of being valued when you were younger for example and twirling your hair and sucking your thumb (Agitation) might have been regarded as endearing when you were seven and possibly a great way to manipulate mum and dad, as might throwing a tantrum, throwing yourself on the floor or banging your head (Escalation), but it is all far less effective if you are twenty- six. Behaviours of this sort are so ingrained that they become the automatic response to any given difficult or stressful situation or feeling and are engaged in without the person concerned actually making any conscious decision to engage in them or really being aware of what they are doing on a thought-out; planned fully conscious level. It is often experienced by the individual concerned as something that simply takes over and “just happens.” This is nonsense of course as by definition, behaviour is something that people do and it is therefore always the responsibility of the person or persons concerned. The concept of empowerment obviously incorporates developing an awareness of your automatic default behaviour patterns and coping strategies and replacing those that are ineffective, self-sabotaging, unhelpful or harmful to the self or others with more effective coping skills and modes of behaviour. So the obvious question to ask yourself is; “are any of the four passive behaviours one of my automatic default modes of functioning?”

Coping Mechanisms Simply becoming aware that you have a tendency to engage in any of the four passive behaviours empowers you to stop when you realise you are doing so and then replace what you’re doing with a more helpful activity that effectively addresses the situation. Things like doing nothing, over- adaptation and agitation can be addressed fairly easily simply by recognising the fact that you are engaging in those activities and focusing your energies on doing something more constructive. Escalation is a bit more difficult to nip in the bud and as it is a behaviour that is often associated with distressing feelings that are difficult to contain or process, it needs to be replaced with alternative coping strategies. Deliberate self-harm of various kinds is an example of an Escalation behaviour pattern that is quite common amongst some diagnostic categories of personality disorders and several alternate coping strategies have been developed that many people have found to be immensely helpful. Placing an elastic band around your wrist and repeatedly twanging it is quite painful and has proven to be an effective alternative to cutting for many people. Another effective alternative is to go through the motion of cutting using a piece of ice instead of a blade; which produces very similar physical sensations without actually causing any physical damage. Many people have found that “slashing” themselves with a red felt-tip pen has been an effective way to tackle their destructive self-harming behaviour. These are all examples of non-harmful variations of what is essentially exactly the same mode of behaviour and are given as alternative options or coping mechanisms, when or if, the impulse to self-harm becomes overwhelming, rather than as ways of actually dealing with any given situation or solving problems effectively. Cutting is not the only form of deliberate self-harm of course by any means but with a few moments reflection you should be able to devise similar less harmful alternatives, i.e. holding ice against your arm instead of burning yourself is another alternative.

32 Externalised violence directed towards another person, animal or inanimate object also requires an alternative method of coping with the feelings or emotions driving the behaviour. Any form of strenuous physical exercise is an obvious viable alternative. Anger is often the motivating force behind externalised violence and punching the crap out of a punch bag at the gym and/or lifting weights are both great ways to deal with anger effectively without incurring any negative consequences. The advantage of lifting weights is that you can keep them in a cupboard at home but you need to have a large room if you want to hang up a decent-sized punch bag. Doing push-ups, jogging, hitting and/or kicking a large cushion are also all equally effective ways of dealing with distressing anger provoking feelings. Those options are all very well when those feelings arise when you are alone and brooding, but what happens when you are in a social situation and someone says or does something that makes you feel angry and your immediate impulse is to be physically violent? You obviously need to be able to check the impulse and deal with the situation more effectively. Ironically the most effective way to deal with that sort of situation with an immediate response is to engage in another of the four passive behaviours, Do Nothing. Take a deep breath, count to twenty, stop and think. Situations and events don’t always need any sort of response at all actually, and a thought-out response that has been arrived at after due reflection on the matter is usually much better and far more effective than an immediate reaction to anything. If you feel angry about a remark that someone has made just ignore it, treat it with the contempt it deserves. If you are engaged in a conversation that is making you feel angry stop and take several deep breaths and think about how to express yourself in a way which is not verbally abusive and/or likely to make the situation escalate into violence. If you feel unable to remain in the situation without becoming violent, remove yourself from it, leave, walk away. Deal with the angry feelings by going for a run or going to the gym or doing push-ups when you get home. It is a much more effective way of dealing with anger provoking social situations than being violent and getting arrested, the probable results of which include alienating yourself from everyone and the possibility, even probability, of a prison sentence eventually.

Another effective way to deal with distressing feelings is to take the opposite approach and rather than mirroring self-harming behaviour in a non-harmful way or defusing anger with strenuous physical exercise or spoil and pamper yourself instead. Do something that makes you feel good. Have a nice long relaxing bath with plenty of nice smelling bath salts, listen to soft relaxing music, watch a good film, read a good book, see your friends, go to a sauna or have a massage. Anything that takes your mind away from your destructive impulses and negative thoughts and feelings and makes you feel better. Excluding the use of psychoactive substances like alcohol and street drugs that are likely to become habit forming or addictive, over eating or any other potential alternative forms of self- harm of course. If you’re feeling stressed out, anxious or angry about something and things are getting on top of you and difficult to cope with; it makes much more sense to do something that is going to lift your spirits and make you feel good than it does to hurt yourself in some way or to take it out on someone or something else. Self-harm, substance use and the alternative coping strategies described above are essentially all forms of activity that distract you from distressing thoughts or feelings and the only real difference between effective distraction methods and self-harming behaviours is that the latter are destructive and self-sabotaging while the former aren’t. Whenever you feel overwhelmed by distressing thoughts or feelings that you feel unable to process, distract yourself with the non-harmful coping mechanisms described and/or by doing something relaxing or pleasing. Another effective way to deal with distressing thoughts and/or feelings is to off-load them

33 by telling a sympathetic friend or relative what is happening and how you feel. They can’t solve the problem or process those feelings for you of course but simply telling them about it is an effective way in which the feelings can be processed and released, let go of. If you don’t have a convenient sympathetic understanding friend or relative available, the Samaritans organisation exists for precisely that purpose and is available twenty-four hours a day. You can look in the phone book or phone directory enquiries to get their phone number.

A common feature of Acting Out behaviours like externalised violence and deliberate self-harm is that the powerful feelings that drive it are often related to past events that are unresolved on a psychological level and can result in Escalation behaviour that is not only ineffective and self- sabotaging, but also usually totally inappropriate and completely out of proportion to the present circumstances that trigger it. Unresolved issues from the past and unresolved trauma is something that many people that meet the personality disorder diagnostic criteria have to work through. It is one of the primary reasons why people experience difficulty in dealing with life effectively; as so much of their psychic energy is still preoccupied with those unresolved past events. This which makes it extremely difficult to deal effectively with the present. An element of the empowerment process that also overcomes the tendency to engage in any of the four passive behaviours is gaining the ability to stay focused in the present moment.

Mindfulness Inspired by Eastern philosophies; Mindfulness techniques are a fundamental component of many therapeutic models. In some ways it is a form of meditation but whereas meditation quite often entails either focusing on an abstract idea, visualisation exercises or attempting to clear the mind of all thought entirely, the objective of Mindfulness is to focus the mind firmly in the present moment, on what is happening right now. It has been variously described as…

“The awareness that emerges through paying attention on purpose, in the present moment, and non- judgementally to the unfolding of experience moment to moment.” Kabat-Zin 2003

“The non-judgmental observation of the ongoing stream of internal and external stimuli as they arise.” Baer 2003

“Keeping one’s complete attention to the experience on a moment to moment basis.”

Martlett and Kristeller 1999

So it’s about being consciously focused on the present moment and experiencing exactly what is happening right now, without making any judgments or thinking about it very much at all. It’s simply being in and focusing your entire attention on, and experiencing, the now. Most experienced car drivers usually drive on automatic pilot with their mind occupied by thoughts of what they will be doing later when they arrive at their destination or what happened earlier and often arrive at their destination with only a vague impression or memory of the journey itself. People often find their mind drifting away when listening to a lecture and it is by no means unusual to be thinking about

34 something else when an individual is talking to you. People do a lot of things on automatic pilot actually and most people spend more time thinking about the past and/or day-dreaming about the future, thinking about what to make for tea tonight and how great the gig is going to be next Saturday, or was last Saturday, than they do actually experiencing the present moment at all. Mindfulness is about being in the now. It is immensely difficult to deal effectively with things on a day to day basis when your mind is constantly preoccupied with the past and/or day-dreams of the future and the practice of Mindfulness is an immensely powerful empowering tool that not only enables people to deal with life, events and feelings more effectively, but is also a very effective grounding technique and it enhances the experience of living. To begin with it is a practice that should ideally be done as a specific exercise at a given time; as many times a week as you like; but once you grasp the basics and master the art you will find that you can practice Mindfulness anywhere at any time; whatever you are doing. Ultimately the practice of Mindfulness is about living and experiencing life, each moment, with conscious awareness.

The above may seem like a bit of a contradiction to the concepts of reflection and Mentalisation, but they are not mutually exclusive. There is a time to be reflective and think about how the past influences the present and how others might be affected by your actions, a time to think about and make plans for the future and a time to simply be, with your attention focused entirely on exactly what you are actually experiencing in the here and now. You can think about and analyse it, reflect on it, later if you think you might find it useful to do so.

Neurological studies have found that the regular practice of mindfulness produces improved neurological functioning in those areas of the brain associated with decision making, attention, empathy, the capacity to self-soothe and emotional regulation. It also increases blood flow, reduces blood pressure and reduces the risk of cardiovascular disease as well as improving people’s attention capacity, productivity and job performance (e.g. ability to function effectively). It can lead to enhanced feelings of satisfaction with life. People that practice Mindfulness regularly experience long lasting physical and psychological stress reduction, positive changes in well-being, are able to cope with addictions more effectively and are far less likely to experience feelings of depression and/or exhaustion.

Exercise One – Step One.

Sit in a comfortable chair with your back straight and your feet flat on the floor with hands resting on your thighs, arms resting by your side. Focus your attention on your breathing and breathe in slowly and deeply. Fill your lungs to their full capacity, or to a degree that feels comfortable and then breathe out slowly. Just focus on your breathing for a moment or two. Breathe in to a slow count of four, hold your breath to a count of four, breathe out to a count of four, breathe in again and repeat. People’s lung capacity will vary according to their size and stature obviously but breathing in and out to a slow count of four or five will be about right for most people. If you are a large man with a big chest you might find breathing to a count of six or seven is better, if you are a petite female a count of three might be more appropriate. Feel the air flowing into your nostrils and entering your chest as the latter expands; and feel it leaving. When the slow breathing pattern feels comfortable and regular without requiring much effort or control, focus your attention on your body, feel the floor beneath your feet and the back and seat of the chair on your back, buttocks and thighs. Keeping your attention

35 on your body locate any particular muscular or other discomfort you might have, a slight itch or a bit of wind perhaps. It’s OK; you don’t need to do anything about it, just become aware of it. Stretch your fingers; back and toes and then relax, feel the tension leaving your body and return your attention to your breathing for a minute or two. Now ask yourself how you are feeling at the moment, what is the predominant feeling or emotion? If you have never meditated before it is quite likely that you’ll be feeling a bit silly, but that’s OK, stick with it, let the feeling of silliness pass. You might be feeling sad about something or feeling anxious, which is also OK. Simply experience the feeling and name it if you can. Some people might not be able to name what they’re feeling at all, others might simply experience a feeling of emptiness or lack of feeling, others’ might experience feelings of anger or feel like crying. Whatever you feel is OK, don’t judge the feeling, don’t try to fix it and don’t run away from it, just experience it as it is without attaching any particular significance or importance to it at all - it’s only a feeling, you can cry if want to. The objective of the exercise is simply to experience and focus your attention on the moment, exactly how you are feeling right now. As you do the exercise you will probably have random thoughts about all sorts of things arising in your mind and that is OK too. Just ignore them. Don’t judge them and don’t follow them; just let them arise in your mind and drift away like leaves on the breeze. Save them for later when you work on developing your reflective Mentalisation skills and simply be with the feelings and emotions you are experiencing right now, just feel them and name them if you can. It helps focus your attention inwards if you close your eyes but it isn’t essential, do so if it feels comfortable and keep them open if closing them doesn’t feel OK. Stay with and explore the feeling for three or four minutes before proceeding to step two.

Step Two

Bring your attention back to your breathing and open your eyes if you had them closed and take note of what you are seeing. Whatever is on the wall in front of you, the furniture, the pattern or pile on the carpet. Feel the chair on your back, buttocks and thighs and the floor beneath your feet, the warmth of your hands resting on your thighs and the feel of your thighs on the palms of your hands. What can you hear? The birds or the traffic outside perhaps? Hopefully not the neighbours arguing. Stand up and stretch your back, arms, toes and fingers and relax. Go into the kitchen and make a cup of tea or coffee or other hot or cold drink of your choice. Take note of what you are doing, focus your attention on the way the coffee falls off the spoon into the cup and watch the water rise as you pour it, see the pattern the milk makes as you stir it in, make or pour your drink with awareness, notice what is happening. Take a biscuit or a slice of toast or something to have with your drink. Look at the biscuit, how does it feel in your fingers? Smell it, place it in your mouth and experience how it feels against your teeth and your lips before you bite into it. Consciously focus your attention on how it tastes and feels in your mouth as you crunch it up and how it feels when you swallow it. Likewise, with your drink, look at the cup or glass it is in, experience how it feels in your hand, hold it to your nose and breathe in the aroma. Take a mouthful and hold it in your mouth a moment and experience how it feels and tastes before you swallow it and focus your attention on how it feels when you do. Drink it Mindfully, focus your attention entirely on the experience of drinking, live the moment and experience it with full focused awareness, concentrating entirely on the act of drinking. If you have issues around food you can replace the biscuit with a soft fruit like an orange or something if you like but eating something is always a good way to ground yourself and the idea of step two is partly to focus your attention on the present moment and partly to ground yourself and get you in touch with

36 the here and now reality of the external world after the inner world exploration of your feelings in step one.

Feelings and emotions are a normal, even essential, part of the human experience and some of them can often be difficult to process and deal with. For people that have difficulty dealing with distressing overwhelming feelings and emotions; getting in touch with them in a safe and contained Mindfulness exercise is not only an effective way to deal with them, but also a very effective way of developing the capacity to contain and process them effectively. For people experiencing feelings of emptiness or having difficulty getting in touch with their feelings and emotions, it is an equally effective way of empowering themselves to do exactly that. Step two of the exercise is something that can be done at any time as a grounding technique when/if you are struggling with intrusive thoughts or difficult feelings, focusing your attention firmly on the external reality of now. You can do anything Mindfully, have a bath or a shower, even the washing up; focusing your attention on the way the warm water feels on your hands and the smell of the washing up liquid and the way it shimmers on the plates as you rinse them. Mindfulness is all about being grounded in the reality of the present moment, the external reality of your environment and what is happening right now as well as what is going on for you in your internal world right now. For anyone that struggles with intrusive thoughts or has difficulty containing or processing their feelings effectively, it is a very empowering practice that will enable them to overcome their difficulties in that regard if they make it a regular part of their life. Developing the ability to focus your attention will obviously enable you to perform any task more effectively and taking note of the things you look at, smell, taste and feel opens up a world that is full of pleasurable sensory experiences and enriches life considerably. For people that experience feelings of being detached or isolated from everything, the practice of Mindfulness will empower them to focus their attention on the present moment and engage with things on a much deeper, much more authentic; more real level than before.

Mindfulness is an effective way of actually processing distressing feelings and emotions and gaining control of intrusive thoughts, not just a way of managing or coping with them.

Exercise Two After you have done exercise one a few times you should be finding the experience quite easy and natural and be ready to proceed to the next stage. Exercise two is essentially the same as exercise one but incorporates visualisation. Proceed exactly as in exercise one but this time breathe in through your nose and out through your mouth, visualising strength; healthiness, vitality and life-force entering your nostrils as you breathe in and negativity, anger, sadness etc. leaving through your mouth as you breathe out. Visualise them as streams of light, golden life enhancing solar energy as you breathe in, less vibrant and energising as you breathe out. When you identify the feeling or emotion you are experiencing visualise it as a landscape and look at the sky. It might be a dark night sky if you are feeling sad or tinged with red perhaps if your predominant feeling of the moment is one of anger or anxiety, whatever seems appropriate to you. Visualise the sun rising, as it does the inky night time blackness gets lighter and fades away, or the redness of the sky fades to pink, and is slowly replaced by a beautiful light blue sun-drenched dawn. An alternative visualisation is a murky dirty brown river clearing as it is fed by a vibrant crystal clear water fall. Another variation is to visualise your negative feeling as a coloured balloon that floats away and disappears. You can probably think of similar visualisations of your feelings yourself; whatever seems right for you is the

37 most effective. If you’re feeling OK and not really experiencing any particularly negative feeling that’s terrific, simply visualise yourself standing in a field watching the sun rise and flood you with radiant life-enhancing light. Breathe it in.

An extension or combination of the Mindfulness exercises described above that can be used as a powerful grounding technique at any time, is to have a nice warm bath with nice smelling bath salts or bubble bath. You can incorporate scented candles and/or aroma therapy oils and soft relaxing music if you like. Just make sure that if the music is provided by a portable device it is placed somewhere safe where it can’t fall into the bath. Get into the bath and commence the breathing exercise, focus on the feel of the warm water all around you, the soft silky feeling added by the bath salts. Breathe in their perfume or that of the scented candles or aroma therapy oil. Luxuriate in the pleasurable sensation of the bath; take note of how the soap suds feel as you soap yourself. Soak in the bath visualising all the stress, anxiety, anger, negativity and/or other unpleasant feelings soaking out of you into the bath water. When you feel ready; get .out of the bath and pull the plug; visualising all that negativity flowing away and disappearing down the plug-hole with the water. Dry yourself Mindfully; paying attention to the feel of the towel. Wrap yourself in your dressing gown and make yourself a nice drink, a nice hot cup of cocoa or Horlicks perhaps. Drink it mindfully; really tasting it and focusing all your attention on the experience of drinking. It’s a very effective way of dealing with stress. Chill out and listen to soft relaxing music, watch TV or a DVD, read a book or go to bed. An effective way to help you fall asleep is to stay in the semi-meditative Mindfulness mind-set and simply let whatever random thoughts come to mind arise and drift away without making any judgements about them or following any particular train of thought at all, just let them float up and away like leaves blowing in a gentle breeze. As you are already in a semi-meditative state of consciousness between sleeping and waking anyway it is usually easy to fall into a deep refreshing sleep. Counting sheep or something actually does the exact reverse as you are keeping the mind active by concentrating on counting. Mindfulness is keeping your attention specifically focused on the here and now, internally or externally as the case may be; but the same sort of meditative technique, the relaxed breathing exercise and relaxed state of mind, can easily be incorporated into your reflective Mentalisation exercises, although that is focused reflection and not Mindfulness. As always the labels are really just technicalities, Mindfulness in the pure sense is a very effective art to learn and so is focused reflection in a relaxed meditative state as a form of Mentalisation exercise. There is absolutely no reason why any individual can’t engage in both but it is important to be clear within your own mind if the objective of the exercise is to experience and process feelings and/or emotions that you are experiencing right now - get in touch with them, which is Mindfulness. Reflection on where they stem from and how they influence the present and the way you are, is focused reflection or Mentalisation rather than Mindfulness, and/or if your objective is to reflect on something else, which is also Mentalisation. Writing up an account of your Mindfulness exercises and your focused Mentalisation exercises in your reflective diary, assuming you have decided to maintain one, is a good idea. You will notice a steady improvement in your skills and it will be a useful record of your thoughts and feelings that will probably be very informative when looked at in relation to the daily events that you are also recording. It’s all about developing your self-awareness - climbing into the driver’s seat and taking control of your life.

The Rackets

38 The concept of racket feelings is another component of Transactional Analysis and relates to surface feelings that mask or camouflage deeper emotions. The word “Racket” being used in the context of the American slang term for a con or a scam. Racket feelings are basically a psychological defence mechanism that operates as a protection against deeper distressing emotions that are otherwise too painful or dangerous to deal with or acknowledge. Anger is often a racket feeling that masks deeper feelings of vulnerability, fear, hurt and pain. We live in a culture in which gender roles are still clearly divided to some extent and it is not at all uncommon for men to react with violence of some kind, lashing out at someone or destroying something, when they actually really feel like crying and it is equally common for females to cry when they actually feel furiously ragingly angry. Which stems primarily from the fact that boys are usually bought up to stick up for themselves and to “stop being a big girl cry baby, hit them back,” while girls are usually clearly informed that nice girls definitely don’t go around beating people up and/or deliberately smashing things but it is perfectly OK for them to have a good cry. The “allowed” sanctioned feeling replaces the one that is forbidden or taboo. In some families some specific feelings and emotions are accepted and others are not. Some families do anger very well but no one ever cries or admits to feeling sad or sorrowful for example, while in other families everyone is always very understanding; caring and immensely supportive of each other but the idea of anyone being angry with another member of the family is utterly unthinkable. Some families just don’t do feelings and/or emotions at all, the entire concept is taboo. How in touch with their feelings an individual is and what racket feelings might be masking what deeper emotions is to a large extent dependent on their family traditions in that regard.

Racket feelings are a bit like distraction method coping mechanisms and/or self-harm in the sense that they might help to cope with deeper more distressing feelings in the short term but are actually very unhelpful in the long term. They obscure or distract attention from the deeper emotions and the trauma, that comprise the underlying problems that really need to be dealt with at some point, if the individual concerned is ever going to be able to overcome whatever their real problems are and move on. All the coping mechanisms, the acting out behaviours, the use of alcohol or street drugs as a form of self-medication and many forms of prescribed medication simply distract from or mask the underlying difficult feelings and trauma that needs to be worked through - experienced and let go of, if the problem is ever going to be effectively dealt with and “recovery” (for want of a better word) is ever going to be achieved. The Mindfulness exercises previously described, enable the individual to get in touch with those deeper emotions and stay with them, allowing them to be experienced and ultimately released and let go of in safe contained Mindfulness meditation exercises. It certainly isn’t going to happen all at once in one go. Remember that whatever feelings or emotions are experienced are normal and healthy in themselves and need to be felt and experienced at some point as an essential feature of the healing process, prior to being let go of or released. It can be a painful experience but is an essential part of the empowering healing process. Both in the sense of letting go of painful feelings arising from traumatising events in the past and from the perspective of learning how to deal with and process current feelings and emotions effectively. Staying with the racket feeling in the Mindfulness exercises will eventually lead to uncovering the deeper underlying feelings and emotions hidden behind it - assuming that racket feelings are a feature of a person’s particular complex set of difficulties and therapeutic issues of course, which they probably are. Most people, with or without a diagnosable personality disorder or mental health diagnosis of any kind, usually have racket feelings of some kind. It’s a normal psychological process but is more pronounced when/if the deeper feelings are linked to particularly distressing experiences; feelings and emotions.

39 Anger is often a racket for pain; fear and vulnerability that feels too painful to face and depression that is often internalised anger that feels too potentially volatile and dangerous to acknowledge or deal with, because it feels like an unacceptable feeling towards someone like a parent, child, sibling or partner that you’re “supposed” to love.

Letting Go Life is a process of continual change on all levels. Day changes into night, summer changes through autumn into winter, trees blossom in the spring; give fruit in the summer; let go of their leaves in the autumn and sleep in the winter and so on, the cycles of change apply everywhere. The natural human growth cycle consists of a series of changes; transitions from infancy to childhood to adolescence to young adulthood to maturity to old-age and each change, each transition; entails letting go of the previous state of being and embracing the new. As Axis II psychological development conditions, which they officially are, personality disorders can be seen as arising from difficulties completing the natural psychological growth process on some level and being stuck in an earlier phase in some way. Letting go of the previous phase of development is a natural and continual life process and yet letting go is undoubtedly the most difficult, yet also most essential, part of the psychotherapeutic process. Re-writing your life script, which is essentially exactly what the empowerment process is all about, entails letting go of old outmoded script beliefs engendered by negative imprinting and conditioning etc. and embracing new perceptions, seeing things from a different perspective, developing new skills and moving on to another phase of being.

Letting go of old outmoded script beliefs is difficult enough but the difficulty is often compounded for many people that are struggling with childhood trauma related to things like childhood neglect and/or abuse of some kind. Nothing can ever change past events or make everything better but people do have a degree of control over the extent to which past events overshadow and influence the rest of their lives. It isn’t just the trauma or constant replaying of the memory of the events themselves that needs to be let go of though of course, it’s the feelings and often also the perception of self-association with them as well. Hurt, pain, anger, rage, bitterness, resentment, outrage and indignation are typical normal natural, and in that sense perfectly healthy, feelings for anyone dealing with issues of that nature to have and they are perfectly justified. The problem is that if you are filled with bitterness hurt pain anger rage and resentment the fact that it is a perfectly normal healthy response to events and entirely justified doesn’t really help you a lot, as many people reading this are no doubt all too painfully and acutely aware. You are the person that has to struggle with those feelings every day of your life and whose life is all but destroyed by them as a result. It’s the first thing on your mind when you wake up, stays with you all day and is the last thing you think of at night. You put it on with your dressing gown, wash in it and eat it with your breakfast. It is always there, always in the back and never far from the forefront of your mind, like a constantly playing record that often actually becomes audible in the form of the disembodied voices that many people with diagnosed personality disorders sometimes hear during “psychotic episodes.” Because it is always on their mind and the feelings themselves are entirely justified there is often a tendency for people to unintentionally nurture those feelings; which keeps them stuck firmly in the past and significantly impairs their ability to function effectively on any level and is obviously a source of severe distress. Letting go of childhood trauma and the feelings associated with it is often an essential and immensely significant part of the psychotherapeutic process for many people with a diagnosed personality disorder and the first step in the healing process is to make the decision to do exactly that. To let it

40 go, to leave it all in the past and move on. Which is obviously much easier said than done, but it can be done. That statement probably sounds completely unbelievable to many people reading this but it is a fact and over the years we have known literally hundreds of people that have dealt with exactly similar traumatic childhood experiences and have worked through them successfully, let them go; left it all in the past and moved on. It takes time but by making a conscious deliberate and consistent effort to stop dwelling on the past and focusing your thoughts and energy on the present and future instead; you become increasingly occupied with current and future events and the past occupies increasingly less time in your thoughts. The feelings themselves can be worked through and eventually let go of with Mindfulness, but it doesn’t happen overnight.

Bear in mind the vitally important fact that the objective of the Mindfulness meditations is not to dwell on and nurture difficult or distressing feelings linked to the past but to focus on what you are feeling right now, at the time you do the exercise, which may or may not be linked to past events. To get in touch with; experience and process what you are feeling at that moment and letting the feelings go, not to dwell on or nurture them.

The other difficulty is that feelings often become fused or confused with a person’s sense of their identity. If a person has been full of rage pain anger and resentment since they were about twelve years old the chances are that they probably don’t even recognise the fact that they are angry at all really, they simply feel as they do and relate to life and other people in the way that they relate to them. Powerful overwhelming negative feelings like pain and anger tend to overshadow and dominate the person feeling them and start to feel like their identity but they’re not, they are just feelings not the identity of the individual feeling them. Feelings do not constitute a personality, you are not what you feel and what you are feeling isn’t you, feelings are simply something that people experience. Letting go of those feelings however can often feel like losing your sense of yourself, your identity; although it is actually the exact opposite. The anger, the hurt, pain rage, resentment whatever isn’t you, it’s something you’re feeling that is preventing the real you from emerging. It isn’t only feelings like pain and anger that hold people back of course, negative self-perceptions, pathologising, seeing themselves as a needy invalid or semi-invalid of some kind has the same detrimental effect. Letting go of those feelings and negative self-perceptions is essential for someone to become the person they actually really are, potentially at least, but frankly most people find it as scary as hell, because it is a leap into the unknown. If you’re not actually the living embodiment of pain rage anger and resentment or the living embodiment of desperate neediness you believed you were; who or what are you? The empowerment process is all about letting go, of negative destructive feelings, old outmoded script beliefs, false ego structures, destructive self-sabotaging coping mechanisms; behaviour patterns and self-sabotaging ways of being and embracing new perceptions, developing new skills and moving on and is in every sense a process of self-development and self- discovery. The next step of the reflective process consists of reflecting on what feelings, habitual repetitive thought patterns and/or negative self-sabotaging perceptions, behaviour patterns and coping mechanisms need to be let go of in order for you to be able to move on; to the next phase on your personal journey through the life process of continual psychological development and growth towards the desired state of self-realisation; which is the ultimate goal.

Communication Styles

41 The way that an individual communicates determines the way in which they are perceived by others, the sense that other people have of the sort of person they are, of their personality. In fact, other than by things like dress, hairstyle, art and/or literature, it is actually the only way in which anyone’s personality is expressed and experienced by others and is obviously a vitally important consideration with regard to personality disorders. There are four basic communication styles, Passive, Aggressive, Passive-Aggressive and Assertive.

Passive People with a Passive communication style tend to avoid expressing their thoughts feelings and/or opinions at all. On the rare occasions that they do they are usually presented in a hesitant apologetic manner, as though they are apologising for interrupting because their opinion isn’t really important and probably not even worth hearing anyway, and are usually disregarded by other people as a result. People with a passive communication style rarely get their needs met; which is often a source of resentment on their part. Their body language and manner is submissive with limited eye contact and they allow themselves to be dominated by other people and are often taken advantage of and have their rights and boundaries violated. This usually results in producing feelings of anxiety and of not being in control of their life, often leading to feelings of depression and confusion. People with a passive style of communication will obviously benefit by becoming more assertive.

Aggressive Aggressive communicators express their needs and stick up for themselves in a very direct way. Their body language is usually overbearing, even intimidating, and their verbal communication is often abusive and violates the rights and boundaries of others; which is usually due to their underlying low self-esteem and feelings of powerlessness. They usually have a sense of entitlement combined with a sense of resentment and a feeling that other people, the world, owe them and they tend to regard other people as inferior. They try to control and dominate others and usually resort to blame, criticism and threats. The most common result of an aggressive communication style is that it alienates other people; which leaves the Aggressive communicator feeling isolated and out of control. People with an aggressive communication style will obviously benefit by becoming more considerate of the feelings of others and learning how to express themselves in a way that is still direct and honest but is also respectful of others.

Passive-Aggressive People with a Passive-Aggressive communication style deal with things indirectly. Their body language is often confusing and while they never directly express or confront any specific issues with anyone, their communication usually consists of subtle indirect expressions of anger and frustration and the use of sarcasm to undermine or sabotage other people. It is a style of communication that usually engenders mistrust as it is not straightforward, leaving other people with the sense that the individual concerned never says what they really mean. Instead, it tends to alienate them and leaves them feeling powerless and ineffective. People with a passive-aggressive communication style will obviously gain by learning how to express themselves more directly.

Assertive

42 The body language of assertive communicators is calm and relaxed. They express themselves directly in a way that is polite and respectful of others; which tends to make other people feel calm and comfortable in their company. They have a positive healthy sense of self and do not feel the need to control or dominate other people and are able to stand up for themselves and not allow themselves to be controlled or dominated either. They are neither controlling nor submissive, feeling comfortable calm relaxed and in control of themselves and express themselves in a way that is respectful clear and direct on an adult to adult equal basis, simply as one autonomous adult to another equal, there is no power imbalance in assertive communication.

People will often adopt a different style of communication with different people, adopt a different manner and tone when speaking to superiors, subordinates and/or their friends for example, but everyone has a natural default communication style. Momentary reflection will clarify which communication style is consistent with different diagnostic categories of personality disorder and which one is your usual default communication style.

The communication style that is most effective that everyone should try to adopt and cultivate is obviously the assertive style. Assertive communication is not about winning or being in control, it is about establishing mutual understanding and agreement. Having respect for the other person and yourself and respecting the mutual right to have differences of opinion. True communication entails establishing mutual understanding, negotiation is about arriving at mutually satisfactory agreements, which in practice might often simply be the agreement to agree to disagree. The two most valuable skills of the effective assertive communicator are I statements and active listening.

“I” Statements I statements are one of the most powerful tools in communication. Used correctly they remove any accusatory tone in your statement and allow you to express your point without getting a defensive reaction. There are three important components to an I Statement: (1) Stating your feeling. (2) Connecting the feeling to an issue. (3) Stating what you want to have happen.

Example (1) I feel like I’m being blamed or accused of something, as though it’s my fault or my responsibility, which it isn’t. (2) I know you’re upset because it seems like everything’s gone wrong but taking it out on me isn’t going to help. (3) Can we have a calm rational discussion about this and see if we can do something about it? How do you think we can solve the problem?

Own and accept responsibility for your own feelings. “I feel” is a statement about yourself, about the way you feel that has no direct connection to the other person at all. “You make me feel,” is an accusatory statement about them, about something someone else is doing that makes your feelings their responsibility; which they’re not actually. Accusatory statements like “You make me,” are almost always likely to generate unhelpful defensive responses and are usually a very unhelpful ineffective way of communicating. It is also usually helpful to point out to the other, in a tactful non- accusatory way, that you are not responsible for their feelings either, they are and it is their responsibility to manage and deal with them like a mature adult, as you do, not your responsibility

43 to deal with them on their behalf. The effective use of I statements obviously entails the acceptance of self-responsibility on all levels.

Active Listening Stay Present. In order to communicate effectively it is important to stay focused on the topic at hand. There is always a tendency to bring in past issues, to defend or accuse, which must be avoided. Bringing up the past usually does nothing but confuse and deflect the issue. All too often listening is the last thing that we are doing when the other person is talking. During discussions and/or arguments we are often simply waiting for our turn to speak, or just looking out for the other person to say something that can really be jumped on. If effective communication is going to take place we have to really listen and try to understand what the other person is saying, even if it is something that we may not like. We need to understand what the other person is communicating and understand the others perspective before we are able to give an appropriate response of any kind. The prerequisite of effective communication is to obtain an empathic understanding of the other person’s perspective and/or the matter they are communicating. This can only be done by really listening to what they are saying and striving to see things from their perspective, without necessarily sharing it. The next step is to communicate your understanding of their perspective and the fact that it is a valid way to feel; followed by your own perspective; which is equally valid even if it differs. At this point mutual understanding is established. If there is a specific problem that needs to be resolved; the next step is simply a matter of negotiation, of finding a resolution to the “problem” by arriving at a mutually satisfactory agreement from a position of mutual understanding.

Effective communication is a skill that can be learned like any other and if they really make the effort and consistently try to communicate assertively, people that meet the PD diagnostic criteria have the capacity and potential to become effective assertive communicators, with consistent practice. There is of course never any guarantee that the other person is as effective at assertive communication as you are and therefore no guarantee that every potentially problematic situation will always be peacefully and effectively resolved, but the overwhelming majority could be resolved.

Strokes and Stamps The concepts of strokes and stamps are another feature of the theories of Transactional Analysis about interpersonal communication.

Strokes People “stroke” each other by paying compliments, showing interest and displaying consideration and concern. Simply asking someone how they are feeling indicates a degree of interest in them and their wellbeing and constitutes stroking them. When they reply with “I’m fine thanks, how are you?” their enquiry about your welfare constitutes a reciprocal stroke in return. Complimenting someone on something they have done or telling them that you were impressed by what you thought was a very perceptive comment they made in an earlier discussion also constitutes stroking them, showing your interest and reinforcing their positive sense of self. Human beings are fundamentally social creatures, we typically live in groups and we all need stroking in this way occasionally in order to develop and maintain our sense of wellbeing and self-worth. Giving someone a present or a birthday card, phoning them up to ask how they are, letting them know that they are in your thoughts,

44 showing consideration, paying them deserved compliments, acknowledging their existence and value by showing your interest in them and their welfare are all ways of giving strokes.

Stamps Stamps are the exact opposite of strokes. Going back to the example above; if you politely asked someone how they were and they either completely ignored you or told you to mind your own business you would probably be feeling snubbed, hurt and rejected, which would be the usual typically “normal” response. If you’re standing in a queue waiting to be served and the person behind you gets served first you are likely to feel overlooked, discounted and disregarded; leading to feelings of anger, hurt and resentment. Little things that tend to undermine people’s feelings of self-worth, minor disappointments, upsets and petty frustrations are a fundamental aspect of life that everyone experiences. The negative feelings they engender add up, we tend to collect them like Green Shield stamps or Nectar Card points which we then typically cash in periodically by off-loading our feelings of resentment, hurt anger and rejection onto someone else by being rejecting, dismissive etc. Using them as a target for our frustrations, dumping our stamps onto them basically, cashing some of them in. It is all normal typical human interaction, typical human functioning.

Generally speaking people that give strokes tend to get many strokes back in return whereas people that never give strokes to others rarely get any from other people. Similarly; going around constantly cashing in your stamps on everyone else has a marked tendency to result in everyone else cashing in their stamps on you. It is another classic example of Karma, the operation of the law of return. The reflective processes continue with reflecting on your usual pattern of stroke giving and stamp dumping and how that influences the way in which others relate to and interact with you.

Part Three

As has already been stated several times, Personality Disorders are Axis II psychological developmental conditions, not Axis 1 mental illnesses. The normal healthy psychological developmental process consists of a series of gradual transitions from a strong healthy symbiotic attachment to a primary caregiver in infancy (usually with the mother) to the attainment of independent adult autonomy at some point between the ages of about eighteen and twenty- four, for most people. Essentially Personality Disorders consist of an incomplete or maladaptive psychological developmental process that falls short of the attainment of healthy fully functional adult autonomy in some way. This is not to suggest that Personality Disorders entail any impairment on a cognitive level. Quite the reverse in fact, individuals have to be at least eighteen years old in order to meet the diagnostic criteria of a Personality Disorder, in the cognitive sense as well as chronologically. They have to have full adult capacity on a cognitive level; otherwise they would not meet the diagnostic criteria for PD, they would merit a different sort of diagnosis of some kind, even though they might also have co-morbid personality difficulties falling into the category of behavioural problems or something of that nature. With regard to diagnosable Personality Disorders however; on some level the psychological developmental process has not been completed as it should, leading to huge issues relating to feelings of abandonment and rejection, dependency and/or isolation, difficulty processing or containing difficult feelings and emotions, social phobias, feelings of

45 entitlement, impulsiveness and/or many other therapeutic issues often associated with a Personality Disorder diagnosis.

The point is perhaps best conceptualised using the Transactional Analysis (TA) Ego States functional model. In this model “Ego States” is the term applied to different states of mind that people function in at any given moment in time. For example; in a team meeting and/or while having an intellectual conversation with someone who is on an equal level with themselves; people usually function in an Adult Ego State, as one autonomous independent adult to another, on an equal basis. Alternatively; if a manager or supervisor has to reprimand a member of staff; they are described as functioning in a Critical Parent Ego State and they are described as functioning in a Nurturing Parent Ego State when they are praising them for good work or providing sympathy or support for someone who is struggling. If they are being criticised or reprimanded in some way; most people feel like a child that is being told off and are said to be functioning in an Adaptive Child Ego State. When they are relaxing and having fun, feeling and behaving in a playful mood people are described as functioning in a Free Child Ego State. It is an axiom of Transactional Analysis that a psychologically well adapted fully functional autonomous adult human being functions equally in all three Ego States and that fully functional adults interact with each other effectively in all three Ego States.

Figure 1 Figure 2 Healthy interpersonal Fully functional adults interactions between function effectively in all fully functional adults three Ego States involve all three Ego States

Figure 1 Figure 2

Figure 3

Figure three illustrates the concept of symbiosis. The person on the left is doing all the adult and parental functioning for the person on the right, (as well as for themselves of course) and the person on the right functions more or less exclusively in the Child Ego State. This is a normal healthy relationship between a mother and an eighteen- month old baby but it is a dysfunctional, unhealthily enmeshed relationship between two supposedly autonomous adults. It is however the Figure 3 archetypal “carer” relationship.

From the foregoing TA illustrations it should be aparent that the traditional archetypal “carer” relationship unintentionally encourages dependency and actually reinforces PD. The bizarre irony of the situation is that people with a Personality Disorder or other mental health diagnosis are almost invariably surrounded by well meaning carers, family members, partners, CPN’s, psychiatrists, therapists and support workers that are all trying to do all the parent and adult ego state functioning

46 on their behalf. Thereby disempowering them and simply encouraging dependency and reinforcing the problem, if it is Personality Disorder, in the process. The dilema then is how to empower people to complete the psychological developmental process, rather than taking care of and looking after them; problem solving on their behalf and constantly “rescuing” them. How to hand back power and responsibility to the individuals concerned, thereby empowering them to complete the psychological developmental process to fully functional adult autonomy in a healthy way. How to mirror, support and reinforce the psychotherapeutic process, as opposed to impedeing the process by maintaining the enmeshed symbiosis and reinforcing the problems, as often transpires within the traditional “carer” relationship model. It doesn’t happen overnight of course, it takes time and consistancy, but if the effeort is concistantly made to hand back power and responsibility and interact with them on an equal adult ego state to adult ego state basis people with PD who are locked into dependent symbiotic modes of functioning usually eventually complete the psychological developmental process in a healthy way, especially if they engage with a specialist PD psychotherapeutic service. The point being that they need to be encouraged and supported to do so, not unintentionlly encouraged to maintain a dependent symbiotic relationship by everyone trying to take of, look after, manage and problem solve, or in other words do all their adult ego state thinking and functioning, on their behalf.

You cannot change another person, only the way that you respond to them. If you respond differently however they are then faced with a different situation to which they then have to respond, which is likely to elicit a different sort of response from them in future. Thereby improving the overall relationship dynamic and empowering everyone concerned.

One of the key elements involved in the process of change is for people to empower their relatives by interacting on an adult to adult ego state level. If it is their default mode of functioning their relative will probably still respond from a child ego state at first but over a period of time they invariably adapt and increasingly interact in an adult ego state.

Chapter two Key Concepts

"If I accept the other person as something fixed, already diagnosed and classified, already shaped by his past, then I am doing my part to confirm this limited hypothesis. If I accept him as a process of becoming, then I am doing what I can to confirm or make real his potentialities...

If I see a relationship as only an opportunity to reinforce certain types of words or opinions in the other, then I tend to confirm him as an object – basically a mechanical or manipulable object. And if I see this as his potentiality, he tends to act in ways which support this hypothesis. If, on the other hand, I see a relationship

47 as an opportunity to reinforce all that he is, the person that he is with all his existent potentialities, then he tends to act in ways which support this hypothesis. I have then confirmed him as a living person, capable of creative inner development. Personally I prefer this second hypothesis. If I can create a relationship characterised on my part by a genuine transparency, in which I am my real feelings: by a warm acceptance of and praising of the other as an individual; by a sensitive ability to see his world and himself as he sees them; Then the other individual in the relationship; Will experience and understand aspects of himself which previously he has repressed; Will find himself becoming better integrated, more able to function effectively; Will become more similar to the person he would like to be; Will be more self-directing and self-confident; Will become more of a person, more unique and more self-expressive; Will be more understanding, more acceptant of others; Will be able to cope with the problems of life more adequately and more comfortably. "

Extracted from "On Becoming a Person. A Therapists View of Psychotherapy" By Carl R Rogers. Circa 1961

Enmeshment and Co-Dependency.

Given the nature of some categories of personality disorder it is inevitable that the primary difficulty arising within the interpersonal relationship that people have with their relatives is one of unhealthy enmeshment. There are always at least two people involved in every relationship and even though the individual in the “carer” role may be fully functional and independent in themselves they are still part of the enmeshed relationship dynamic. It is equally inevitable that some of the designated “carers” are likely to be as emotionally dependent on their relative as their relative is on them and locked into an essentially co-dependent relationship with which they unknowingly collude.

Boundaries

Personality Disorders can be seen as a set of problems consisting of difficulties around the concept of boundaries. Things like deliberate self-harm entailing the breaking of what is generally regarded as a fundamental bodily boundary. This together with lack of awareness and/or total disregard of the needs and/or rights of others, are features associated with assorted diagnostic categories at one end of the spectrum and self-imposed isolation, rejection of others amounting to the creation of a barrier corresponding to the great wall of China between the self and the rest of humanity, at the other end. A distorted sense of boundaries permeates Personality Disorder to the extent of there often being a great deal of confusion over the sense of personal identity, the sense of where the self ends and another begins - often leading to overwhelming dependency, equally overwhelming compulsions to control, and/or complete lack of any sense of empathy, attachment to or connection with others at all, according to which specific diagnostic categories you have in mind. The result is that people that meet the criteria for a diagnosable Personality Disorder, having little or no sense of personal boundaries themselves, or a confused sense at best, almost invariably violate the boundaries of others, albeit often unknowingly. On a practical level this almost always entails totally unreasonable

48 expectations of other people and/or patterns of behaviour that impose on others in some way and are generally regarded as unacceptable on the part of a mature responsible adult; in most social circles. The “carers” of people with a PD diagnoses often come to accept the totally unacceptable for the sake of an easy life. They may find themselves locked into a relationship in which their own needs and boundaries are totally disregarded and they are perceived to exist entirely for the benefit of the other person; without any realistic expectation of ever actually having any of their own needs met. The first thing that most people involved in a close personal relationship with someone with PD need to think about and focus on is regaining their own sense of boundaries and putting them in place in their relationship with their relative.

It is a truism that things always work both ways and “carers” sometimes assume a degree of responsibility and authority over their relative that is completely incongruous. Quite often assuming that they have the same parental authority and responsibility over a thirty-four-year-old as is normal for the parent of a four-year-old, with the expectation of being included in all aspects of their relatives’ life, often to the extent of including an expectation of inclusion in their clinical treatment and a sense of entitlement to see their confidential medical notes. This creates an interpersonal dynamic that often leads to them being as intrusive and controlling in their relationship with their relative as someone that meets the criteria for a diagnosable personality disorder themselves. Most people usually need to develop a sense of personal boundaries and establish them within their relationship, together with an equal sense of and respect for the privacy and other personal boundaries of the other person in that relationship. To establish a sense of a separate identity to the other, take a step back and allow each other to be. Neither requires the others permission to be who they are and neither of them needs to approve of the other. Equally; neither of them should feel the need for the others approval. This applies equally to the parents of adult offspring, and their offspring, as to people that are in a marital style relationship with someone.

The boundaries that people establish within their relationships with their relatives’ need to be fair, reasonable and consistent and the boundaries of the other’s need to be respected by both parties. If their boundaries become inconsistent they will undoubtedly be transgressed and violated and the individuals concerned will be back to square one, maintaining and reinforcing an unhealthy, enmeshed personality disordered interpersonal relationship.

Normalising.

Conflict within close personal relationships is perfectly normal. Husbands and wives often say and do things that are displeasing to the other and parents often disapprove entirely of their sons and/or daughter’s lifestyle choices and people in families often disagree strongly with each other’s core beliefs and values. It is all absolutely normal and perfectly healthy. If an individual is diagnosed with a Personality Disorder however, or any other mental health diagnoses come to that, there is a marked tendency for anything and everything that they say or do that others find disagreeable or disapprove of in some way to be automatically pathologised and regarded as a “symptom” of “their condition.” Consequently, any underlying problems in the relationship are invariably attributed to “their mental health problems” and more or less disregarded as a “genuine” authentic problem in the relationship that needs to be validated and addressed - invalidated in other words. Most of the work in specialist

49 Personality Disorder therapeutic services has to do entirely with interpersonal relationship dynamics, far more than with illness or pathology. The tendency within interpersonal family relationships is for things to become pathologised and therefore dismissed as unsolvable or unreal in some way. This applies equally to parental and marital style relationships. Mental health issues obviously create stress and tension in any relationship but by the same token; tension and conflict in any relationship has a detrimental effect on the mental and emotional wellbeing of all concerned. People end up on an ever decreasing downhill spiral in which relationship conflict has a detrimental effect on everyone’s mental and emotional wellbeing; which obviously creates more relationship conflict which has an increasingly detrimental effect on everyone, ad infinitum. A primary objective of this guide is to empower people to be able to interrupt the downward spiral process before things deteriorate to the point that both people in the relationship are in need of an intensive psychotherapeutic intervention or psychotropic medication of some sort.

Validation. As pointed out in the section dealing with normalising; once they acquire a mental health diagnosis everything that a person says or does that someone else disagrees with or disapproves of in some way tends to get pathologised, dismissed as a symptom of “their condition.” The cumulative effect of this is that the person concerned, and their concerns, are invalidated, regarded as in-valid. On the one hand there is a tendency for people to make allowances for them and excuse behaviour that others would be held accountable for in some way and on the other hand; any of their opinions beliefs or convictions that someone else disagrees with tend not to be taken seriously, people humour them, they are dismissed as in-valid. If their feelings are often invalidated, a person grows up feeling that their emotional responses are not correct and/or of no significance. Over time, this can result in confusion and a general distrust of one’s own emotions, difficulties containing and processing them and/or a lack of regard for the feelings of others. The core belief that people’s feelings are of no significance and can therefore be totally disregarded.

Validation is not about agreeing or disagreeing or about winning or losing. It is about communicating with someone on an emotional level. You do not have to share or agree with the opinion of another in order to understand their perspective and recognise the fact that, although it differs from your own, their view point is also perfectly valid. It is perfectly OK to agree to disagree, the important thing is that both people need to have a sense of being heard and understood, of being validated as a human being whose thoughts and feelings matter and are as important and valid as everyone else’s.

Difficulty processing and/or containing overwhelming emotions and feelings is a core feature of some categories of personality disorders and often leads to behaviours that seem completely disproportionate to most people. While condoning the behaviour itself is usually not at all helpful; it is important for people to recognise the fact that the feelings themselves, the level of distress, is absolutely real and valid, albeit completely disproportionate to the situation, from your perspective. You can validate the reality of the feelings without condoning the behavioural response to them.

Once again; everything always works both ways. People in the “carer” role often fall into the trap of “walking on eggshells” and finding themselves in a one-way relationship in which their feelings are regarded as being of absolutely no importance whatsoever and they are not entitled to have any

50 needs of their own at all. Everyone’s needs need to be met on all levels; both parties to the relationship need validation. The concepts of Validation, Normalising and Boundaries are inextricably linked. They reinforce each other and operate in both directions, apply equally to both parties in the relationship. People need to be encouraged to establish a healthy equal relationship with their relative; incorporating shared responsibility in which the needs and feelings of all concerned are recognised and respected by all concerned, a mutually empowering relationship in which everyone is validated. Responsibility not Blame.

People tend to rescue those who self–harm and/or indulge in other self-destructive behaviours, which is unhelpful and disempowering for the individuals’ concerned as it takes away their responsibility to keep themselves safe, reducing them to the level of a child in effect. In contrast there is often little or no empathy with people who are aggressive or chaotic and the natural tendency is to blame them for their chaotic behaviour, even though all of the behaviour above, is caused by the same personality disorder.

The concept of responsibility entails the precondition that a person has a degree of control over their behaviour, can choose to act otherwise and can learn new ways of coping with feelings and problems. They can be supported and cared for in this process but it is their responsibility to deal with the problem.

Blame on the other hand is a response to another because of their behaviour and usually entails feelings of anger, resentment and disappointment leading to judgments (disapproval, condemnation) that in turn often lead to a punitive response of some kind like rejection and/or withdrawing love and support. The concept of blame entails an attitude of entitlement to negative feelings, judgements, and actions, because the other person deserves it.

Doctor Hanna Pickard http://www.philosophy.ox.ac.uk/members/hanna_pickard

The concepts of blame, responsibility and rescuing are themes that constantly occur in some form. People often blame their relatives for causing them distress by their behaviour, are often blamed for everything by their relatives and often blame themselves. Ideally people should stop assuming responsibility for their relatives and encourage them to accept self-responsibility instead, without blaming them, and to stop blaming themselves.

Working with the concepts of “Empathy not Rescue” and “Responsibility not Blame” is a fundamental element of Validation and a crucial feature of establishing healthy empowering relationships.

The hypothetical case vignette below clarifies the difference between blame and responsibility, empathy not rescue.

John is a twenty-six-year-old married man with a five-year-old son and a three-year-old daughter. Fundamentally he is actually a very caring considerate man but he is deeply traumatised and has

51 enormous difficulty containing, processing and dealing with overwhelming feelings of anger and resentment stemming from the experience of having a violent, aggressive alcoholic father, who was a very domineering, controlling, physically abusive man that frequently used to beat John’s mother, John himself and his siblings on a regular basis. At the age of thirteen John vowed that he would be nothing like his father and really tries to make a consistent and determined effort to be exactly the opposite in every respect. He hates his father with a vengeance though and is overwhelmed with powerful feelings of anger and resentment towards him. As a result, he is constantly angry and often has immense difficulty controlling his temper, especially if he has had a few drinks. Inevitably his wife and children, as the people closest to him, often tend to be the innocent recipients of all those negative; destructive feelings and emotions. As hard as he tries to be the exact opposite of his father, the truth is that he is almost exactly like him. No one is more aware of that fact than John and as a result he actually hates himself even more than he hates his father, which simply constantly reinforces his feelings of anger, aggression and resentment. He is trapped, caught in a psychological vice that just gets tighter and tighter as each day goes by. If you have any empathy or understanding at all; you really can’t blame John for being the way he is, it isn’t his fault. It is however his responsibility to deal with the problem and do something about it, and his alone. He actually is the only person on the planet that has enough agency in their life to make any effective changes to the situation at all. The fact that he had an abusive childhood does not mean that it is OK for him to take it out on his wife and kids and/or the rest of the human race, it is not an excuse. He is still as responsible, and accountable for, his behaviour as everyone else. You can empathise with John and appreciate the enormity of the problems he is dealing with but that does not relieve him of responsibility and/or excuse him taking it out on everyone else. It is John’s problem at the end of the day, something which has to do entirely with him, his internal universe, which he alone has to manage and deal with, because he is the only person on the planet that can. The responsibility is his - and his alone.

Responsibility not Blame, Empathy not Rescue, but also: - Empathy not Blame, Responsibility not Rescue.

Authenticity. In anything other than a professional capacity, a carer relationship contains an element of artificiality or inauthenticity. It is a rescuing role which is neither an authentic marital relationship nor an authentic relationship between a parent and their adult offspring and is disempowering to both parties. Everything revolves around the “patient” and the carer’s needs go unmet. For the sake of a quiet life the carer usually spends their life “walking on eggshells” in an attempt to not say or do anything that might distress the “patient” and provoke a difficult stress provoking reaction of some kind. There is usually some attempt to distort reality around the “patients” pathology, to wrap them in cotton wool, keep them safe and away from anything that might cause them distress and/or trigger their pathology, which obviously simply reinforces their dependency. Their inability to deal with life effectively is precisely what is wrong and what needs to be challenged and rectified, creating an artificial realty in which they never have to deal with anything stressful because someone else always does so on their behalf does not help them at all, it makes them worse. The difficulties are often compounded by the fact that the designated “carer” inevitably inhabits the same artificial universe; which is likely to threaten their own sense of reality and ultimately entails them reinforcing a

52 fundamentally unhealthy co-dependent relationship in which they collude, albeit usually unknowingly.

There is also an immense power imbalance in a “carer” relationship which is usually immensely unhelpful. In most non-professional “carer” relationships, the term “carer” is often experienced by both the “carer” and the “patient” as more or less synonymous with “keeper.” The most effective intervention that a “carer” can make is to establish an authentic relationship with their relative. To stop trying to be their relative’s psychotherapist, psychiatric nurse and support worker all rolled into one and go back to establishing an authentic caring supportive marital or parental relationship in which they also have needs that need to be met and responsibility is shared. The concept applies equally to parents establishing an authentic relationship with their adult offspring in which their offspring have a degree of independence and responsibility that is entirely appropriate to their actual chronological age as it does to people involved in marital style relationships.

Empowerment The concept of empowerment is a thread that runs throughout the concepts of Boundaries, Normalising, Validation, Responsibility and Authenticity. The role of “carer” is; by definition; the role of a rescuer. Rescuers solve other people’s problems by rescuing them and problem solving is something that practically everyone in a “carer” role will probably do on their relative’s behalf on a daily basis without really being aware of the fact. By definition empowerment entails handing back power and responsibility to the other person. Solving someone’s problems is very helpful to them in the short term but once again tends to reinforce their dependency. The long term helpful intervention is to teach them the knowledge and skills that will enable them to solve their own problems in future. It is the difference between telling a child the answers to their maths homework and helping them to work out the answers for themselves by demonstrating the equations on your fingers or with oranges or something and teaching them to relate the figures on the page, the sums, to real life realities. Rescuing and problem solving on their relative’s behalf is something that most carers do constantly, it is far more empowering and therapeutic for people to start supporting their relatives to solve their own problems and make their own decisions instead, thereby empowering everyone concerned.

Distress Tolerance There are ten different diagnostic categories of personality disorders and the characteristics associated with one are practically the exact opposite of another. In addition, people usually have a primary diagnosis of one diagnostic category combined with secondary characteristics of others, so it is impossible to make a single statement about PD that applies to every diagnostic category; much less to everyone with a personality disorder diagnosis. One of the prevailing characteristics often associated with PD however is a limited capacity to contain and/or process overwhelming feelings and emotions effectively, low distress tolerance. If someone you love is in distress the natural instinct is to do whatever is necessary to alleviate their distress, which is another form of rescuing. The only way that anyone ever learns to deal with anxiety and stress effectively is by dealing with it. People need to stay with their distress and work through it without resorting to unhealthy self-destructive coping mechanisms like self-harm or self-medication, in order to develop the capacity to process feelings and emotions and cope with life effectively. Constantly trying to alleviate their relative’s distress is unhelpful and disempowering in the long term. It is far more empowering and therapeutic

53 to simply be with them and validate their feelings, to cultivate the practice of supporting their relative to deal with difficulties, rather than trying to deal with them on their behalf, to cultivate the practice of simply “being with” rather than “doing to” or “doing for.”

Momentary reflection should clarify the fact that all the foregoing concepts are inextricably linked and overlap. To summarise; the core concept is for people to stop assuming responsibility for their relative and hand power and responsibility back to them and establish an authentic collaborative equal relationship in which each other’s personal boundaries are mutually respected, responsibility is shared, everyone’s needs are met and everyone is validated.

People need to be asking their relative “how can we get through this together?” either as a couple or as a family as the case may be. As opposed to asking themselves “how can they get the other person through this?”

To paraphrase Carl Rogers; People need to establish an authentic relationship with their relatives and accept them as the unique individuals they are

Chapter three.

Common Features Associated with PD.

IMPORTANT

An estimated eight to fifteen percent of people with a Borderline Personality Disorder diagnosis successfully complete suicide every year! The programme of empowerment, handing back responsibility and establishing boundaries needs to be implemented consistently in a gradual process over a period of time with insight, understanding sensitivity and care. People need to encourage and support their relatives to make positive empowering changes, and develop their strengths, not suddenly start making demands, imposing strict boundaries and laying down the Law!

Suicidality, Self-Harm, Substance Misuse, Eating Disorders are by no means always a feature of a diagnosable personality disorder but they are certainly issues that are very common and more

54 prevalent with some diagnostic categories than with others. They are issues that constantly arise in specialist personality disorder psychotherapy services and in Carer support groups. They are also all potentially fatal. It is beyond the scope of this manual to deal with any of them in depth but some general considerations and guidelines are pertinent.

Suicidality. Suicidality and suicidal ideation is far too complex an issue to be adequately dealt with in this manual, so suffice it to say that there is far more than one suicidal state of mind and the distinction between suicide and para-suicide needs to be made. The word suicide describes the deliberate and intentional act of self-destruction, self-murder. Para-suicide on the other hand, is a phrase that describes potentially life threatening acts of deliberate self-harm resorted to as a coping mechanism that is not deliberately designed to kill, as the core intention is to live. The constantly reoccurring tragedy of course is the simple fact that the ambulance doesn’t always arrive in time. The relatives of people with a personality disorder diagnosis are often faced with extremes of self-destructive behaviour like suicide attempts and para-suicide. The trauma and stress they incur as a result is enormous. People often feel or become invested with total responsibility for keeping their relative alive. Sometimes it is a responsibility that the “carer” appropriates and places on themselves, rather than one that is placed upon them by their relative. It can also sometimes feel like a particularly pernicious form of emotional blackmail although it is not always deliberate or fully conscious on their relative’s part. It obviously follows that an alertness to the potential risk and a heightened level of nurturing support when situations that are likely to trigger a suicide attempt or Para suicidal self-harming behaviour occur is essential but the totally unacceptable reality, which has to be accepted none the less, is the fact that no one can be responsible for keeping someone else alive, especially if they engage in potentially life threatening behaviour. Carer support group facilitators need to encourage people in the group to be nurturing and validating but; none the less; refuse to accept responsibility for the life of their suicidal or para-suicidal self-harming relatives and hand power and responsibility back to the individual concerned, back to their relative where it belongs.

Self-Harm There are many different reasons why people self-harm and people often do so for different reasons at different times. It is something that people do as a coping mechanism and constitutes a temporary solution to a problem, not a problem in itself, to the individuals concerned. It is an ineffective self- destructive way of coping. Most people tend to regard their relative’s self-harming behaviour as the problem when in fact, from their relative’s perspective; it is usually the only thing that helps them to cope with whatever the real problems are. There is no doubt that in the long term self-harm is not an effective coping strategy and is self-destructive and needs to be addressed. Which is all very well if the individual is engaged with an intensive psychotherapy service which is addressing the underlying problems that drive the self-harming behaviour and teaching them other effective healthy coping strategies, but not everyone’s relatives are. For many people deliberate acts of self-harm is their only coping mechanism. A judgemental punitive response tends to create feelings of self- deprecation which reinforces the drive to self-harm while an overly sympathetic nurturing response entails the self-harming behaviour eliciting positive attention; which also reinforces the drive to self- harm. Careful non-judgemental neutrality is the most appropriate and effective response, simply accepting the fact that the individual self-harms as a way of coping and more or less ignoring the fact, while also gently encouraging them to develop more effective coping strategies and engage with

55 specialist services, assuming there are any in the area. A few more scars aren’t exactly a major disaster after all. If the self-harm is para-suicidal, of a nature to be potentially life threatening, the situation is somewhat different of course. It is not so much the risk of the individual self-harming that has to be assessed as the potential consequences if they do.

Irrespective of the degree of severity; self-harming behaviour of any kind is usually very distressing, even traumatising, for the relatives of the individual concerned, the people in the Carer support groups, and they will usually need a great deal of support to accept their relatives self-harming behaviour as a coping mechanism.

Substance Misuse. If the statistics for drug and alcohol use are combined; approximately 15% of the adult population will have a substance misuse problem of some kind at some point in their life; although only 2.8% of the population will ever have a physical addiction to a psychoactive substance of any kind. A much larger percentage of the population, practically everyone actually, uses some sort of psychoactive substance, legal or otherwise, recreationally and do not have a problem with that at all. Once again the problem of substance misuse resides in the fact of it being an ineffective coping mechanism. Something that people resort to in order to cope with whatever underlying difficulties they are dealing with; that is almost invariably regarded as the problem itself by everyone else. From the psychotherapeutic perspective the problem is compounded by the fact that in order to engage with psychotherapy and deal with their problems effectively a person needs to be in touch with their feelings and emotions, drug free in other words, and they have to stay with their distress in order to be able to work through it, which they obviously won’t be if they blot everything out with alcohol, street drugs and/or many forms of prescribed medication. The paradox is that they will never be able to overcome their substance dependency until they deal with the underlying psychological issues that drive it but they will never be able to deal with those until they are drug/medication free and stone cold sober. In recent years some progress has been made in the treatment of dual diagnosis so the situation is not quite as completely hopeless as it sounds. The important things to bear in mind is that the substance misuse is usually symptomatic of the problem, an ineffective coping strategy, not the problem itself and that a substance dependency is not the same as an addiction in the true sense of the term, which entails an actual physical need for the substance, not simply a desire or craving. Another thing to remember is the fact that these days, irrespective of the legal situation, the recreational use of a wide range of psychoactive substances constitutes what has to be regarded as a perfectly normal social life for most people in their mid-teens to mid- twenties. It is the pattern of usage that needs to be considered. If someone is unable to get through the day without using and/or reach for a bottle of alcohol or pills or a hypodermic syringe every time they feel anxiety or stress they are using a substance as a coping mechanism, self-medicating essentially. Statistically this constitutes a substance misuse problem but is usually regarded as a temporary solution to problems, not as a problem in itself, by the individual concerned. If they simply do a lot of social drinking or use recreational street drugs for recreation at the weekends it is highly likely that it is simply a lifestyle choice which has absolutely nothing whatsoever to do with personality disorder or any other mental health issue, even though their preferred drug of choice might be illegal and/or their relatives may disapprove entirely.

Eating Disorders

56 Eating Disorders are immensely complex and too vast a subject by far to attempt to even begin to deal with adequately in this document but they often start out as a coping mechanism that provides an illusion of being in control which then actually takes over like an addiction and controls the individual concerned. The distress that the relatives of people with diagnosable eating disorders experience is absolutely hideous, it is difficult to imagine anything that could possibly be more distressing and/or emotionally debilitating than watching anyone you love slowly starve themselves to death and being absolutely powerless to do anything about it. Anorexia Nervosa is not the only eating disorder associated with personality disorders of course, only one of several, they are all potentially life threatening and indescribably distressing to the relatives of those that meet the relevant diagnostic criteria. As a PD Carer group facilitator the best advice you can give anyone in the group whose relative is dealing with an eating disorder is that of the National Centre for Eating Disorders.

National Centre for Eating Disorders Carers Guidelines The words below in blue italics are added by us Don’t accuse or label Don’t focus on eating Don’t walk on eggshells Don’t assume responsibility and tell them what to do all the time. Don’t try to make them eat or stop exercising Don’t collude with the illness Challenge denial (which is a fundamental part of anorexia) in a caring non- judgemental supportive way Maintain your boundaries Be Honest, authentic Try to be there as a supportive friend, not in a parental “carer” role Listen and validate their feelings Accept them as the unique individual they are

Violence and Aggression Violence and aggression can be a feature of some, but by no means all; or even most, personality disorders. Sometimes the aggression is limited to violent verbal interactions and sometimes it entails physical violence. There will always be some people in a carer relationship with someone with some categories of a PD diagnosis who feel intimidated by their relative and there will undoubtedly be those that feel physically afraid of them, usually with good reason based on past experiences. The possession of a personality disorder diagnosis does not morally or legally excuse violent and/or other criminal behaviour. People with a personality disorder diagnosis have full adult capacity and are as responsible for their behaviour as everyone else, morally and legally. If someone is being intimidated by their relative, they need to maintain their boundaries and refuse to tolerate unacceptable verbal or physical abuse and if they are met with physical violence they should call the police and have their relative arrested and legally prosecuted for the criminal offence.

It is probably relevant to point out the fact that in this context the phrase “verbal abuse” means something far in excess of simply being sworn at and/or fairly typical family arguments, it implies being subjected to torrential verbal assaults. It is probably also equally relevant to

state the fact that it is by no means unknown for the relatives of people with some categories of a personality disorder diagnosis to be in fear of their lives because of their relative’s sudden unpredictable mood swings and their capacity for violence.

57 Isolation/Withdrawal Self-imposed isolation is quite a common feature of some forms of PD and it is not at all unusual to have people whose relative spends practically their entire existence in their bedroom with occasional forages to the kitchen for food and/or trips to the bathroom. Self-imposed isolation to that extent is obviously completely dysfunctional and such individuals are usually almost entirely dependent on their relative, in whose home they live, to meet absolutely all of their needs from maintaining a roof over their head and providing them with food to dealing with all necessary transactions with the outside world on their behalf. They are also usually markedly reluctant to engage with services and/or seek help of any kind, often not recognising the fact that they have a problem that needs to be addressed. People who find themselves with a relative whom they hardly ever see but sometimes hear moving about in other parts of the house, much like having a ghost or poltergeist, are best advised to empower their relative by encouraging them to engage with their GP and other services. Another empowering intervention is to refuse to deal with other people and/or organisations on their behalf but insist on them accepting the minimal level of responsibility by doing so themselves. They can always accompany them and provide moral support if need be, to begin with anyway, with the objective of empowering them to deal with matters on their own in the not too far distant future.

Carers are entitled to a carer’s assessment that is designed to ascertain the level of support they need in order to support their relative. The difficulty is that their relative usually needs to have an official diagnosis of some kind in order for them to be officially regarded as a carer. They can however also request a psychological assessment of their relative. A potential outcome of having a carer’s assessment is that the person in the carer role may be allocated a social worker who can assist with finding alternative accommodation for their relative. This will probably be sheltered supported accommodation if it is deemed to be necessary, which will also result in finally engaging the individual with services and obtaining the help and support they need.

In order to arrange a carer’s assessment, the first port of call is the GP. They often conduct the assessments themselves although different organisations sometimes have that role in different parts of the country, in which case the GP should know and should be able to arrange it.

It is recognised that the concept of requesting a psychological assessment for their relative and the concept of them moving out and living independently are likely to be met with a degree of reluctance on the part of both the carer and their relative and are presented as ideas to consider. Which is exactly how the carer should be presenting the ideas to their relative of course, as an empowerment plan to be pursued consistently over the next year or two. The idea is for people involved with carer support groups to consider adopting a more constructive attitude and

58 encourage and support their loved ones to engage with services and find independent accommodation, not to simply kick them out.

None of the behaviours associated with Personality Disorders are mutually exclusive and people usually engage in several. It is common-place for someone to have an eating disorder, self- medicate with street drugs or alcohol, self-harm and become verbally abusive when they are challenged in any way, for example.

Escalation. If a particular action or style of behaviour has elicited a specific response over a number of years, the most likely result of any change in that response is for the individual concerned to engage in a more extreme version of the same sort of behaviour. They up the stakes in other words. People need to aware of the fact that the initial response to the implementation of change, maintaining boundaries, handing back power and responsibility etcetera, is most likely to be an escalation in problematic behaviours like self-harm, self-medicating and all the other behaviours referred to above. Things will usually get more intense for a brief period of time before they start to improve.

The essence of mature adult autonomy is the fact that the individual has self-responsibility. They are a mature responsible adult and accountable for their behaviour and have the fundamental right to make their own decisions and lifestyle choices. They do not need parental, or anyone else’s, permission or approval. Teenage rebellion is an essential feature of the psychological developmental process towards the attainment of independent adult autonomy. By attempting to control their relative’s behaviour people simply reinforce the need for them to do whatever it is that is being frowned upon and not to do whatever it is that is approved off, as the only means of asserting their personal authority and expressing their self-identity and “adult” independence at their disposal. People in the group obviously need to maintain their own personal boundaries and set up boundaries around what happens in their living space but they also need to respect their relative’s personal boundaries and their right to make their own lifestyle choices, even if they disapprove of them entirely.

Chapter Seven. The Therapeutic Journey

59 There are many different therapeutic models for the treatment of Personality Disorders. Some are essentially maintenance programs ,some are short term lasting for a limited period of about sixteen to twenty weeks which are designed primarily to provide the individual with life skills that help them manage their problems more effectively and/or to see things from a different perspective and some are long term intensive psychotherapy programmes that last for at least a year, sometimes longer, and are designed not only to empower people with more effective life skills and reflect on their perspective but also work on a very deep level leading to the abreaction (letting go) of trauma that often drives assorted destructive behaviours and is the underlying cause of many peoples difficulties, as well as providing the opportunity to redo the psychological developmental process within a contained supportive group environment. Regrettably, at the time of writing, services for the treatment of PD generally are still relatively sparse and very much something of a post code lottery and the situation is even more acute with regard to the latter long-term intensive psychotherapeutic services. The concepts presented in this manual are drawn from a wide variety of therapeutic models and theories but this guide will not explain or explore any of them in depth, as if anyone wishes to practice them they will need to train and obtain the necessary professional qualifications to do so, it is however relevant to raise awareness of the therapeutic journey itself.

Three Steps Forwards, Two Steps Back In the entire history of psychiatry and psychotherapy there has never been a single case in which the client has engaged in the programme and consistently improved at a steady rate. The psychotherapeutic process, for everyone, entails periods of progress beset with a series of relapses. When a personality disordered person engages with therapy and noticeably improves, it obviously promotes feelings of hope and positive anticipation in their friends and families. When the relapses occur however it invariably engenders feelings of despair. The therapeutic journey is a process of three steps forwards and two steps back, for everyone. It is important that any people who are involved in a caring or supportive relationship with a personality disordered person, are aware of that fact and are able to hold onto the thought that three steps forwards and two steps back is still one step further forwards than they were and that if they continue in that fashion they will eventually reach the goal of recovery. Otherwise they are likely to become despondent and tend to deal with situations in unhelpful ways that exacerbate the situation and impede the therapeutic process. People need to understand from the outset that the journey to recovery is going to be a long haul that is going to be beset with setbacks and will probably be quite traumatising for all concerned.

The Wall Completion of an intensive long term psychotherapy programme is a major life changing experience that takes several months to process and assimilate. After completing their psychotherapy program, most people struggle with feelings of trepidation about the future together with a deep sense of loss bordering on feelings of bereavement. During this period, they are likely to revert to old self

60 destructive patterns of behaviour, their old coping mechanisms like self-harm etcetera, as a way of attempting to work through that process. From their relative’s perspective they often seem to have reverted back to exactly how they were before they entered therapy, which usually engenders feelings of panic and despair on their part. Their natural response to that is usually to go back to treating their relative exactly as they used to before, like a semi invalid and this will more or less annihilate all the benefits their relative gained in therapy. It is important for carers to understand that what appears to be total regression is in truth a perfectly natural process and an essential feature of the recovery process known as “The Wall.” It is something that everyone has to go through prior to moving on to total recovery and leaving their therapeutic issues behind. The duration of the process varies, it can be a one off incident for some people and/or something that might last for a few weeks or even two or three months for others but everyone hits the wall at some point between three to six months of leaving therapy before they manage to leave their therapeutic issues behind entirely and adopt the positive coping mechanisms and ways of being that they learnt in therapy as their default modes of functioning. Carers, family and friends need to be aware of these facts in advance so that they anticipate it happening and deal with it effectively without panic and desperation and without negating the beneficial effects of the psychotherapy and disempowering their relative by going back to treating them like a semi-invalid.

Chapter Nine What is particularly unhelpful to people that meet the criteria for a diagnosable Personality Disorder?

Being dehumanised and treated like an object of some kind. Being treated like an invalid or as someone that is totally incapable. Being treated like a child. Being treated dismissively. Being treated like someone that is mentally retarded. Being shouted at. Being called manipulative and/or attention seeking. Being told to pull yourself together. Other people making decisions that affect you without consulting you. Focusing entirely on behaviour and ignoring inner turmoil. Being deprived of recourse to physical means (self-harm) when it is your main or only coping mechanism. Being expected to conform to rigid inflexible rules that serve no discernible purpose. Lack of clear and/or inconsistent boundaries. Being patronised. Having every action pathologised. Being ignored. Having your concerns trivialised.

61 Carers4PD. www.carers4pd.co.uk Useful Websites Carers 4 PD www.carers4pd.co.uk

British and Irish Group for the Study of Personality Disorder (BIGSPD) www.bigspd.org.uk/

Out of the Fog outofthefog.net/

National Personality Disorder Programme www.personalitydisorder.org.uk/

Personality Disorders - Mental Health Foundation www.mentalhealth.org.uk/help-information/me

The Personality Disorders Institute www.borderlinedisorders.co

Amazon Books www.amazon.co.uk/

Other Reading. Client Centred Therapy Carl R Rogers Counselling for Toads Robert de Board Dealing with Depression Trevor Barnes Depression, A Nurses Experience Veronica Burton Depression, The Way Out of Your Prison Dorothy Rowe Games People Play Eric Berne Man’s Search for Meaning Viktore E Frankl Mindfulness Mark Williams and Danny Penman On Becoming a Person Carl R Rogers

62 Overcoming Borderline Personality Disorder Valerie Porr Personality Adaptations Van Joines and Ian Stewart Relative Stranger Mary Loudon Stop Walking on Eggshells Paul T. Mason and Randi Kreger TA Today Van Joines and Ian Stewart Transactional Analysis in Psychotherapy Eric Berne The Schopenhauer Cure Irving D Yalom Voices Beyond the Border Lucy Robinson and Vicky Cox What Is Madness? Dorian Leader The World Is Full of Laughter Dolly Sen

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