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STRUGGLING STRIVING SURVIVING
STRUGGLING STRIVING SURVIVING
Living with Borderline Personality Disorder
Dr Jenny Tohotoa
Copyright © 2013 by Dr Jenny Tohotoa. ISBN: Softcover Ebook 978-1-4836-0294-3 978-1-4836-0295-0
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Rev. date: 03/05/2013
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Overview of Struggling, Striving, Surviving................................. 15 Chapter One. .................................................................................................... 19 1.1 BACKGROUND................................................................................... 19 1.2 INTRODUCTION............................................................................... 21 1.3 DEFINITION OF TERMS................................................................... 23 1.4 ETHICAL CONSIDERATIONS. .......................................................... 24 Chapter Two. ................................................................................................... 25 2.1 DEFINITION OF PERSONALITY...................................................... 25 2.2 DEFINITION OF PERSONALITY DISORDER................................. 25 2.3 CLASSIFICATION OF PERSONALITY DISORDERS....................... 27 2.4 PREVALENCE OF PERSONALITY DISORDERS.............................. 27 2.5 DIAGNOSIS OF BORDERLINE PERSONALITY DISORDER. ......... 27 2.6 CO MORBIDITY WITH BORDERLINE PERSONALITY DISORDER.............................................................. 28 2.7 DEFINITION OF BORDERLINE PERSONALITY DISORDER....... 29 2.8 SELF-INJURY AND SUICIDALITY.................................................... 30 2.9 FACTORS IN THE DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER.............................................................. 31 2.9.1 Psychological factors. ........................................................................ 31 2.9.2 Biological factors.............................................................................. 32 2.9.3 Social factors.................................................................................... 32 Chapter Three................................................................................................ 34 3.1 INTRODUCTION............................................................................... 34 3.2 QUALITATIVE RESEARCH................................................................. 34 3.3 THE GROUNDED THEORY METHOD............................................ 35 3.4 DATA COLLECTION.......................................................................... 36 3.4.1 Selection and characteristics of participants...................................... 36 3.4.2 Research Interviews.......................................................................... 36 3.5 DATA ANALYSIS: DATA CODING PROCEDURES........................... 37 3.6 WRITING UP THE FINDINGS.......................................................... 37 3.7 TRUSTWORTHINESS, CREDIBILITY AND TRANSFERABILITY OF FINDINGS........................................ 38
39 4............................................................................................................. 65 6............. .. 49 4.........................................1..... 41 4........................................5....... 56 Chapter Six........... 71 6..................... 45 4...2 STAGE ONE: LEARNING TO SURVIVE......2 Damaged by loss of mother..................................................2 Hospital care—negative: contributing to increased vulnerability......................... 43 4.. 52 5... 60 6.....1 Adaptive behaviours.....................................................7 Physical abuse..............4 Being damaged..........................................................................................1 Hospital care—positive: contributing to seeking safety......... 60 6................................................................................................7 Summary............................................................................... 55 5.....3 Living in a dangerous world. 56 5....2 Feeling alienated.................................................1 Consequences of fear of abandonment........ ......... 58 6..................................................4............. 69 6........5 Ambivalence about living....................................1 Consequences of physical abuse..........4................... 53 5...........................5 Neglect and Maltreatment.....1 Introduction....................1 Consequences of loss of self............................1 Consequences of neglect and maltreatment...............................3....................... 1 AN OVERVIEW OF STRIVING FOR AUTONOMY..... 50 4...................................... 64 6..................................................... 50 Chapter Five................ 68 6................................................................................6 Seeking safety.............. Damaged by being isolated:...................................Chapter Four......................... 70 6.........................1 Consequences of feeling alienated........3.......... 40 4....4 Attention seeking..........3 Communication difficulties......... 52 5.......1 STAGE ONE OF BEING VULNERABLE...........2................... 1 Consequences of “Living in a dangerous world”.............................................. 46 4................3......................................6...... 43 4................8.......................................4 Fear of abandonment......................... ...............2........................................1 Drug use...................................4.................................3 Reacting to being damaged............. 43 4..... 66 6......................................4......7................... 61 6........... 39 4..4.......2 Overview of stage one of being vulnerable.....................4........................................ 49 4.................................1 Consequences of communication difficulties................ ..................................6.................... 44 4...............................................................2 Alcohol use................................3 Physical abuse.................4....... 46 4.................................. 61 6. .. ...........6 Sexual abuse.6.........4 Self-harming behaviour.. 73 ....1 STAGE TWO OF BEING VULNERABLE: STRUGGLING TO CONNECT.... 66 6..... 42 4....................................................................................... 58 6..... 55 5........................................................................................................ 53 5........................... 65 6............................................1 Consequences of sexual abuse:...........................................................8 Loss of self..................
....................................... Role of employment................................1 Internal conflicts................................................................................ 85 8..... 96 9............. 96 9............. 107 9........................ 87 8................2 Medication-positive effect............................. 88 8....................................1 STAGE THREE: TAKING MORE CONTROL.....1 Ways of taking control.......................................................................................................................................3.......................................................................... 85 8................................... 108 Chapter Ten..................2.....................1 Medication-negative effect.........................1 STAGE TWO: FINDING ANSWERS..........................................2............1................2........................ 86 8..........................................................2.................3..................... 79 7... .................... 74 7...........................................3.........2 Turning Point...2..........2 Increased self worth....4 Family influence: positive...........................................3.................................... 107 9............................................... ...........2 Stigma.................................................... 95 9......... 100 9................................... 101 9.........................2.............. 79 7........................2...........................2... External conflicts................................. 110 10..............1 Positive formal support................................................1 THE FINDING OF STRIVING FOR AUTONOMY TO OVERCOME BEING VULNERABLE WITH OTHER RESEARCH FINDINGS AND THEORIES................. 97 9.............. 98 9............. ................3 Compounding symptoms.................1 Therapeutic intervention......... 74 7................... 82 7................................................ 97 9................................................................3 Self protection...... ................................3 LEVEL OF SUPPORT................. ..........................1 CO MORBIDITY-INFLUENCES/IMPACT OF AN EXISTING MENTAL ILLNESS...... 81 7...... 75 7...........2........1 Positive response to diagnosis.............. 82 7......................................... 80 7....................................................................3............................. 83 Chapter Eight....1 Intolerance and ignorance from others.........................5. .........................1 Injustice.......... ...........3 Finding a sense of self.....3.................. 93 Chapter Nine..................4 Acquiring new skills........2 LOW THRESHHOLD TO STRESSORS DUE TO INCREASED VULNERABILITY................................................ 110 ........ ............................1.............................................................. 82 7....2...... 78 7................................................. 104 9......................................................................... ...1......................1.............2 Moving forward........................3.................... 75 7...Chapter Seven...................3 Engaging in practical measures.....................1 Formal support............................ 90 8................... 95 9................................2 Negative response to diagnosis...5 SUMMARY.......................................... Informal support..................2........2................................................5 Family influence: negative...4................................... 77 7............................... .....
10.1.1 Maslow’s Hierarchy of Needs....................................................... 110 10.1.2 Erik Erikson’s eight stages of development. ................................... 112 10.1.3 Attachment Theory...................................................................... 114 10.2 A comparison of striving for autonomy to overcome being vulnerable with Cicchetti and Toth’s (2005) “Child Maltreatment”.. ...................... 115 10.3 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with McDonald and Morley’s (2001) “Shame and non-disclosure: A study of the emotional isolation of people referred for psychotherapy.”........................................................................ 116 10.4 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with studies on self-harming Rosenthal, Cukrowicz, Cheavens, and Lynch’s (2006) “Self-punishment as a regulation strategy in BPD.”............................................. 118 10.5 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with the current models of treating people with BPD.................................................... 119 10.5.1 Dialectical Behaviour Therapy..................................................... 119 10.5.2 Schema—focused therapy............................................................ 120 10.5.3 Supportive Psychotherapy............................................................ 121 10.6 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with McDonough, Wynaden, Finn, McGown, Chapman, & Hood’s (2004) “Emergency department mental health triage consultancy service: an evaluation of the first year of the service.”................................................................................ 122 10.7 Summary of the discussion................................................ 122 Chapter Eleven............................................................................................ 124 11.1 IMPLICATIONS OF THE FINDINGS............................................ 124 11.1.1 Initiatives directed towards government planners in the Health Department..................................................................................... 124 11.1.2 Initiatives directed towards health professionals, mental health professionals in particular................................................................. 126 11.1.3 Initiative directed towards universities.......................................... 127 11.1.4 Initiatives for teachers and day care centre staff............................ 128 11.1.5 Initiatives for the general population............................................ 129
11.2 LIMITATIONS OF THE STUDY..................................................... 130 11.3 FURTHER RESEARCH. ................................................................... 130 11.4 CONCLUDING STATEMENT. ........................................................ 131 References. ..................................................................................................... 133 Appendices...................................................................................................... 149 Appendix 1: Diagnostic and statistical manual of the American Psychiatric Association classification of disorders (DSM-IV-TR)......................................................................... 149
Table of Figures
Figure 1. Overview of Struggling, Striving, Surviving. ............................................ 18 Figure 2: The basic social psychological problem:Being Vulnerable....................... 40 Figure 3: The basic social psychological process: Striving for Autonomy. ............... 59
This book is dedicated to all those people who struggle with childhood abuse and betrayal and who continue to strive for autonomy. The book is the result of editing a four year Masters by research thesis and includes actual experiences and incidents as relayed to the author. I would like to take the opportunity to thank all those participants who gave of their time and shared their life experiences with me. I hope you feel they have been respectfully explored and accurately described. To my two supervisors for the Master’s thesis who contributed their expertise in academic writing and qualitative research methods: Professor Dianne Wynaden and Mr Brenton Lewis. To Dr Karola Mostafanejad for her skill and passion in editing and revising the manuscript to better reflect the participants’ voice. The book was written for health professionals, people diagnosed with a borderline personality disorder and for anyone who lives with or cares for someone with borderline personality disorder. It was written to enlighten health professionals and the general public to the “lived” experience of borderline personality disorder. It is a reminder of the incredible strength and persistence people can muster in their struggle to survive. It was also written to emphasise the need for greater empathy and sensitivity for people who have survived childhood abuse and betrayal.
About the author
Dr Jennifer Tohotoa has worked as a nurse in mental health for 30 years. Over the last 15 years, she specialised in the area of working with consumers who have a diagnosis of borderline personality disorder (BPD), both as a nurse and a counsellor. During that time, she has observed an overt negativity from health professionals in the community and in both the public and private health sectors to people with BPD. There is a tendency to negate their symptoms and a lack of compassion and empathy for their repeated self-harming or suicidal presentations to hospital. Lack of training and education about BPD is the most likely cause of this attitude and can hopefully be addressed. The seemingly manipulative, regressed and overt behaviours exhibited by people with BPD can overwhelm already over taxed staff, but the potential for improvement in this consumer group is she worth the time, effort and expense. Jennifer believes people with BPD struggle to get their needs met within the current healthcare system and subsequently act out their frustrations, further alienating them from their caregivers. She supports short crisis admissions for stabilisation of acute suicidal ideation, followed up closely in the community with a key worker. Clinical supervision and support for the key worker is essential to stop staff ‘burn out’, from the emotional intensity involved with caring for BPD consumers.
Two stages of the basic social psychological problem of being vulnerable emerged from the data. not having their feelings and emotions validated and being uncertain how to “be”. that participants engaged in to manage the problem of living in a dangerous world. Surviving The findings of this study are based on identification of the core category and its relation to subcategories. stable environment in which to flourish. Three aspects of struggling to connect were identified in the data as feeling alienated. Participants experienced an ongoing battle with being around people. physical and emotional abuse. friends and strangers that left them vulnerable and fearful. Striving. In the first aspect. fearful and anxious. participants described their experiences of being damaged by parents. which was conceptualised as being vulnerable. feeling awkward. family. thinking differently and seeing things from a different space. The findings identified a basic social psychological problem common to all participants. sexual. communication difficulties and fear of abandonment. Participants talked about feeling different from other people. The damage involved neglect and maltreatment. entitled striving for autonomy. many of the participants talked about their sense of futility and expressed their sense of alienation.Overview of Struggling. This abusive childhood led the participants to experience the second aspect called loss of self and led to confusion with interpersonal relationships identified by never knowing who to trust. Not knowing who to trust. and a basic social psychological process. Family and friends were seen as ‘good’ or ‘bad’ with 15 . The first stage was called living in a dangerous world and involved two aspects. Not having a consistent. living in fear and unsure of how to be safe led many of the participants to the next stage of being vulnerable called struggling to connect.
Participants related their need to escape their dangerous world and this frequently involved illicit drug use and abuse and the use and abuse of alcohol in an effort to relieve the constant anxiety and distress they experienced. When the participants reacted . ambivalence with living and seeking safety. the first stage of striving for autonomy. so many of the participants had difficulties with their relationships and with their ability to adequately communicate their needs or wants. Participants’ movement through the stages of the process was not related to the amount or type of abuse experienced in childhood but to their experience of being vulnerable and the conditions influencing that experience. The self-harming acts sometimes became suicide attempts and these desperate measures were described by several of the participants. many of the participants initiated self-harming behaviours of self-mutilation and overdosing. The basic social psychological process of striving for autonomy was a three-stage process and these stages were: reacting to the damage. When drugs and alcohol were ineffective in reducing the feelings of despair. to get acknowledgement for and attention to their psychic pain or to relieve the unbearable tension they felt. found many of the participants coping in a perceived maladaptive manner through the use and abuse of drugs and alcohol and engaging in serious self-harming behaviours. The second stage of the basic social psychological process of striving for autonomy was called finding answers. To enable the participants to manage being vulnerable they engaged in the basic social psychological process of striving for autonomy. while for others it meant containment and safety in a hospital admission. For some participants the self-mutilation was a way to feel alive.16 Dr Jenny Tohotoa no degree of compromise. loneliness. For some participants this included getting married. The fear of abandonment was explored by some of the participants and highlighted their vulnerability to rejection and their inability to take criticism without self-punishing. This stage consisted of two aspects: turning point and gaining insight. The final aspect of reacting to the damage saw the participants seeking safety. Many participants talked about having suicidal ideation and experiencing a sense of futility and joylessness that added to their vulnerability rather than decreasing it. finding answers and taking more control. emptiness and shame. Reacting to the damage. survive and secondly to continue their striving for autonomy. This acknowledgement of their increasing vulnerability led to participants searching for safety to enable them to firstly. Data analysis revealed there were three aspects to reacting to the damage: perceived maladaptive coping mechanisms.
The last condition to affect the participants struggle for autonomy was the level of support the participants experienced in their lives from family. participants were beginning to learn about their BPD. Struggling to understand their constantly changing moods and the ongoing emptiness that participants expressed. they became more vulnerable and self-abusing. The first condition was the co morbidity—influences/impact of another mental illness and it highlighted the added difficulty some participants experienced with another illness superimposed on their BPD. found many of the participants in crisis. for others it meant making a commitment to themselves and decreasing the self-harming. Many of the participants engaged in some form of formal therapy and continued to learn survival skills that would assist in their battle for autonomy.Struggling Striving Surviving 17 to their damage. This stage saw the participants engaging in self-fulfilling behaviours rather than self-destructive behaviours and thereby increasing their quest for autonomy. The second condition was the low threshold to stressors due to increased vulnerability and recognised the heightened intolerance to both stress and anxiety that the majority of participants experienced. the finding of striving for autonomy to overcome being vulnerable saw participants move from a state of extreme fear and mistrust . All the participants reacted to the turning point by changing aspects of their lives to reduce their vulnerability and increase their striving for autonomy. Taking more control consisted of three aspects that were identified as moving forward. For most participants. To enable them to survive. Participants experienced intermittent suicidal ideation but were now more able to control the intent. In this stage. Three conditions were identified in the data that influenced the basic social psychological problem of being vulnerable and the basic social psychological process of striving for autonomy. the turning point consisted of a significant personal crisis. In summary. For some participants that meant finally having an explanation for their dysfunctional lives. which prompted drastic action to find some meaning to their lives. this meant giving up drugs and alcohol and participating in life. for others it meant another form of discrimination and alienation and it took them longer to be able to reduce their vulnerability. they were more able to move towards the next stage of taking more control. engaging in practical measures and acquiring new skills. friends and health professionals. For some participants. As participants gained insight into their disorder. and a diagnosis of BPD. their self-harming behaviour and suicidal thinking needed to change.
18 Dr Jenny Tohotoa to become more aware of themselves as individuals. Striving. . Co existing mental illness 2. Surviving THE BASIC SOCIAL PSYCHOLOGICAL PROBLEM: BEING VULNERABLE THE BASIC SOCIAL PSYCHOLOGICAL PROCESS: STRIVING FOR AUTONOMY STAGE ONE: 1. gaining insight into the disorder of borderline personality and turning that insight into learning more about appropriate coping skills.1 Living in a dangerous world (a) Being damaged (i) Neglect and maltreatment (ii) Sexual/physical abuse (b) Loss of self STAGE ONE Learning to survive Reacting to the damage STAGE TWO Finding Answers 1. Overview of Struggling.2 Struggling to connect (a) Feeling alienated (b) Communication difficulties (c) Fear of abandonment STAGE THREE Taking more control INFLUENCING CONDITIONS 1. Low threshold to stressors due to increased vulnerability 3. Figure 1. Level of support.
as public mental health outpatients and services have focussed on the needs of consumers with schizophrenia and bipolar disorder. clinicians who understand the complexity and purpose of the self-injuring behaviour are better able to provide consumers with supportive and empathic care (7). 8). mirroring the consumer’s vulnerability (11). introduces the reader to borderline personality disorder. 6). engage in angry and self-destructive behaviours (10). they have not met the needs of individuals with BPD. is about coming to an understanding of what such behaviour means to the person (4). Conversely. It is clear that knowing how best to treat a person with BPD. Treatment providers’ responses to individuals with BPD range from being over-involved with excessive emotional investment to being detached with excessive self-protective distancing. Being frustrated by treatment options that do not meet their needs. Consumers who self-injure may perceive they receive poor care in hospital emergency departments and are then re-traumatised by these experiences. Traditionally. They are seen as being difficult (9). incorporates a definition of terms and describes the ethical considerations undertaken for the study. particularly if they self-injure.1 BACKGROUND People with BPD can present as among the most challenging patients encountered by health professionals in clinical settings (1-3). which could account for their poor treatment compliance (5. 1.Chapter One Chapter 1 includes the background and purpose for the book. consumers with BPD are likely to eventually feel abandoned and in an effort to been seen. People diagnosed with a BPD are often stigmatised within the health system as their repeated admissions create frustration in clinicians (1. The medical 19 .
Mental health nurses were least optimistic about outcomes (18. Working with people with this disorder has been costly to society and has extracted an enormous emotional toll from friends and family (15). To enable health professionals to more effectively care for people with a BPD. even though the prognosis often has a better outcome than many other mental diagnoses like schizophrenia and bipolar disorder (20). Similarly. and estrangement from family members (13). and appropriate specialist referral and treatment for people with BPD. sexual and emotional abuse. without blame or judgement. child abuse. Those with BPD are again confronted with the rejection.20 Dr Jenny Tohotoa and psychiatric systems tend to play out the main features of the developmental history of the individual who enters the system. Adults with BPD are considerably more likely to be the victim of violence. Promoting public and professional awareness of living in a dangerous world is needed to facilitate early identification. support and supervision to facilitate the building of cohesive and productive teams in order to provide adequate care to consumers with BPD (21). substance abuse. intervention. Acquiring an understanding of the experience of living with BPD will give health professionals an increased awareness of the difficulties encountered by this consumer group. which is detrimental to both consumers and staff and creates dangerous environments that exacerbate rather than alleviate consumer distress. they need to understand the consumer’s experience of managing their life with a diagnosis of a BPD. The complexity of these consumers leads to both extended and extensive therapy time (17). abuse and neglect which was characteristic of their early lives (12). Few researchers have explored BPD from the consumer’s perspective. physical. A diagnosis of BPD is linked to high rates of divorce. including rape and other crimes. they are perceived to be involved in many social public health problems (14). O’Brien and Flote (1997) identified that health professionals knew little about this consumer group and this lack of knowledge impacted on consumer outcomes (23). Deans and Meocevic (2006) identified . Individual staff responses to care have been found to be intrinsically linked to team splitting in relation to this consumer group (22). It is essential that staff receive appropriate education. As a group of people. It is postulated that this may be the result of living in a dangerous world as well as impulsivity and poor judgement in choosing partners and lifestyles (16). 19).
How an individual manages that stress and maintains harmony is largely determined by the coping mechanisms they possess which were developed during the early years of life (28). Fallon (2003) found that people with BPD valued their contact with psychiatric services despite negative experiences and encountering negative staff attitudes (15).2 INTRODUCTION Aspects of living in the 21st century place extreme stress on every individual. despite adversities and/or opportunities that are present throughout the lifespan (30). . An increased understanding of BPD also has the potential to enhance health professionals’ levels of satisfaction when working with these consumers. whilst decreasing their levels of stress. feelings and affect. that often includes sexual abuse. by families and the general population (29). Research has also demonstrated that long-term treatment with appropriately trained professionals leads to the consumer’s decreased vulnerability and increased capacity to contain impulses. Increasing the collaboration between consumers and health professionals is supported in the policy document on education and training for health professionals “to learn about and value the lived experience of consumers”(27) (p1). understanding self-injury and safe guarding opportunities for dialogue (25). 1. which in turn will further influence the efficacy of treatment. Without co-ordinated and skilled therapies. but also because they are frequently stigmatised by health professionals entrusted with their care and treatment. which will enhance consumer outcomes. emotional abuse and neglect. physical abuse. Nehls (1999) suggests that mental healthcare for persons with BPD could be improved by confronting prejudice. Both genetics and environment help to shape the individual’s ability to survive and succeed. This book will assist the community’s understanding of living in a dangerous world and providing health professionals with a greater understanding of BPD from the consumer’s perspective will hopefully facilitate more positive attitudes and collaboration. People diagnosed with a BPD constitute a vulnerable population not only because of the natural history of the disorder. with consequent improvement in social functioning.Struggling Striving Surviving 21 that the stigma directed to these consumers limited their access to care and these consumers were frequently labelled ‘manipulative’ by staff (24). the likelihood is that there will be a continuation of costly self-destructive behaviour and impoverished lives (26).
40). Kreisman and Strauss (1991).22 Dr Jenny Tohotoa Research has consistently demonstrated that health professionals experience strong negative emotions. As a result of these injuries they seem to have developed a lack of emotional skin feeling agony at the slightest touch or movement (38). in reflecting the helplessness of health professionals to treat this disorder. As seen by health professionals. This book. interrupted educational pursuits. which leads to further difficulties in developing a therapeutic relationship or positive outcomes from treatment (22). which displayed elements of both psychosis and neurosis (34). BPD is a diagnosis that carries pejorative connotations. Their lives can be a chaotic landscape of job losses. The severity of these insults is revealed in likening people with BPD to people with third degree burns over 90% of their bodies.8) (35). The stereotyping of people with BPD and the pessimism about their treatment has led to staff members developing overt subjective feelings. broken engagements and recurrent hospitalisations (38. The term borderline is a misnomer first used in 1953 to describe a syndrome. and linked to therapeutically nihilistic attitudes (33). neglect or abuse as young children and as a series of events that trigger the onset of the disorder as young adults (36. 2. Stimulate a passion and the [person with] borderline [personality disorder] emotionally bleeds to death” (p. describes how people diagnosed with BPD managed their life within the Western Australian context and the findings make a significant contribution to the understanding of that experience. referred to BPD as emotional haemophilia claiming. utilising the grounded theory method. These consumers are inclined to work their way through large health systems by being perceived as treatment demanding and simultaneously treatment resistant (32). As a result. 37). BPD is one of the most important . the lives of many patients with BPD are experienced as intense and kaleidoscopic (39). Researchers claim that people develop BPD as a result of a combination of individual vulnerability to environmental stress. 31). a diagnosis of BPD is etiologically contentious. The symptoms of BPD may be similar from one person to the next but each person has a wide range of symptoms that may lead to marked disability and ongoing suffering for that individual (41). “a [person with] borderline [personality disorder] lacks the clotting mechanism needed to moderate their spurts of feeling. notably more anger and less sympathy when interacting with consumers diagnosed with a personality disorder (1. and proves difficult to deal with clinically.
1. In this study. mental health nurses and allied health staff. health professionals referred to those qualified in mental health. Effective long-term treatment by appropriately trained professionals leads to the person with BPD learning to manage to live in a dangerous world and highlights their heroic efforts to overcome their vulnerability. . an increased understanding of this consumer groups’ experiences of managing life with BPD will add to existing knowledge and facilitate a more informed understanding of how best to work with this group of individuals. Mental health: The World Health Organization (2003) defines mental health as a “state of well-being whereby individuals recognize their abilities. Anyone who uses the mental health services. This included psychiatrists. are able to cope with the normal stresses of life. Health professionals: Any person qualified to care for or treat others in health matters. new directions and increased treatment options for people with BPD will provide greater levels of support and better health care outcomes for these consumers.Struggling Striving Surviving 23 causes of social and psychological long-term impairment in both treated and untreated populations (42) because of the enduring effects of BPD on the individual. Therefore. psychologists.3 DEFINITION OF TERMS The terms used throughout this study will now be defined: Participant: Consumer: Those people who volunteered for the study and had experience of the phenomenon under study. Furthermore. work productively and fruitfully and make a contribution to their communities” (47). It is also associated with high usage rates of medical and psychiatric services (15. 43-45). Co-ordinated and skilled intervention programs increase the likelihood that the costly self-destructive behaviour and impoverished lives of people who experience BPD are curtailed (46).
all of the participants were able to debrief any concerns or difficulties they experienced within the interview process successfully. the researcher explained the purpose of the study and the process of interview: the where. have presented to hospital at least once with BPD symptoms.24 Dr Jenny Tohotoa 1.4 ETHICAL CONSIDERATIONS Permission to conduct the study was obtained from Curtin University’s Human Research Ethics Committee and followed the guidelines in the Statement on Ethical Conduct in Research Involving Humans released by the National Health and Medical Research Council (1992) (48). and that no identification was recorded on the audiotape or transcribed interview. and how long. Because of the researchers advanced counselling skills. No participant expressed undue distress during data collection for this study. During this initial contact. Issues of confidentiality were emphasised and participants were assured that the researcher was the only person who could link their names with data. Participants were assessed for eligibility to take part and had to have a diagnosis of BPD. before leaving the interview. how. Permission was also sought from the participants to present the findings in publications. All participants signed and kept a copy of the consent form prior to commencing the interview. when. be able to speak and understand English and be over 18 years old. especially the issues of sexual abuse and maltreatment. although the very nature of the disclosures was distressing. The data obtained in this study were recorded and stored in a locked cupboard and in an appropriately referenced form in accordance with the Data Storage and Retention Guidelines outlined in the National Health and Medical Research Council’s (1992) in their National Statement on Ethical Conduct in Research Involving Humans (48). All participants who volunteered for the research contacted the researcher by telephone before any interviews took place. .
it is postulated that people with a diagnosis of personality disorder display common personality traits that seem inflexible and maladaptive causing significant functional impairment or subjective distress (52-54). Suicide and self injury are explored and factors related to the development of borderline personality disorder are identified. 2. Each dimension of personality involves a combination of complex multiple genetic and environmental factors that interact to influence the way an individual directs and adapts to their life experiences (49). They do not represent episodic disturbances. their personal characteristics that distinguishes them from another. like mental illnesses such 25 . In the mental health literature. culminating in the adult personality (50). Each individual’s personality reflects a persistent means of dealing with life’s challenges and a certain style of relating to others around them (51).Chapter Two Chapter 2 includes the definition of personality. The prevalence of personality disorders and the co existing mental disorders associated with borderline personality disorder are described. as defined in the mental health literature. personality disorder and borderline personality disorder and how these disorders are classified. are disorders of personality with an early onset and pervasive effects (55). Temperament arises from our genetic endowment and is influenced by the experience of each individual. 2.2 DEFINITION OF PERSONALITY DISORDER Personality disorders.1 DEFINITION OF PERSONALITY Personality can be defined as that which is unique about a person.
The rigidity of their belief systems and behaviours seems to prevent versatility of thinking and limits the use of problem-solving skills and more effective coping strategies when they are confronted with new or stressful events (58). self-preoccupied attitude with a lack of individual accountability that results in a victim mentality and blaming others. interpersonal functioning and impulse control (59). Research interest in people with personality disorders is a relatively new phenomenon compared to the extensive research literature on those with schizophrenia. It seems that they emerge from the interactions between temperamental vulnerability and the cumulative effects of multiple psychosocial difficulties like abuse and neglect (40). bipolar illness or major depression (56). Personality disorders are among the least understood and recognized disorders in both psychiatry and general medicine and. According to Rey (2005). the way in which information is reported and received. . people with personality disorders visit their doctors more frequently than average with a variety of acute and chronic problems. as well as help with the patient’s ability to manage their lives (62). society and the universe for their problems (60). among the most common. the patient’s response to injury. receive more prescriptions. personality disorders emanate from childhood and the quality of the family environment before the age of 12 years remains the most robust developmental predictor of personality disorder in young adults (57).26 Dr Jenny Tohotoa as schizophrenia. This diagnosis also includes a low sense of self and skewed view of the individual’s identity (55). Psychiatric theory sees personality disorders as a heterogeneous group of disorders that seem to arise when people’s personality traits are considered maladaptive and inflexible. management and risk of developing many subsequent physical and mental disorders (63). affectivity. According to Vaknin (1999) individuals with personality disorders seem to mainly focus on a self-centeredness that manifests itself through a me-first. Possibly due to inappropriate care. have more tests run and are referred more often to obtain a ‘second opinion’ or counselling from various specialists (64). A diagnosis of personality disorder is based on the presentation of cluster symptoms involving cognition. depression or Alzheimer’s disease (61). ironically. Appropriate care by developing a therapeutic alliance can affect the prognosis. Undiagnosed personality disorder and unsuitable treatment can influence the outcome of care.
It is estimated that between 40%-65% of individuals who commit suicide meet the criteria for a diagnosis of a personality disorder. APA 2000) or the International Statistical Classification of Diseases and Related Health Problems. Originally. Joyce et al (2003) found that between 30 to 60% of mental health consumers with other psychiatric diagnoses had a co-existing personality disorder. Mental disorders such as anxiety. (DSM IV-TR. 2.4 PREVALENCE OF PERSONALITY DISORDERS The frequency of personality disorders in the general population is thought to be 10 to 30% (67).Struggling Striving Surviving 27 2. 2000) diagnostic criteria for BPD requires five of nine categories to be met (see Appendix 1). manic-depression and major depression are on Axis I (22). 1992). 2. and general medical conditions associated with psychiatric disorders along Axis III. (ICD 10. The DSM-IV-TR groups personality disorders into three clusters. Furthermore.3 CLASSIFICATION OF PERSONALITY DISORDERS Currently. occupational and psychological functioning (65). text revision (DSM IV-TR). dramatic and anxious but are now simply termed A. WHO. The importance of increasing the knowledge base of BPD to attempt to decrease the casualty rates of suicide cannot be overstated. fourth edition. personality disorders are classified using categories outlined by the two major health classification systems: Diagnostic and Statistical Manual of Mental Disorders.5 DIAGNOSIS OF BORDERLINE PERSONALITY DISORDER The Diagnostic and Statistical Manual version—DSM-1V-TR (APA. Axis IV denotes psychosocial and environmental problems such as stress associated with the disorder and Axis V deals with the level of social. 69). tenth edition (ICD-10). based on descriptive behavioural similarities (59). with BPD being the most common (68. Both the DSM-IV-TR and ICD 10 classification systems describe ten specific personality disorders. These categories include: frantic efforts . B and C (66). Personality disorders and mental retardation are classified on Axis II. Diagnosis using the DSM IV-TR is based on assessment over five axes. schizophrenia. these three clusters were termed odd.
overspending. recurrent physical fights) and transient. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. constant anger. Similarly. There are chronic feelings of emptiness with intense and unstable relationships causing repeated emotional crises. alcohol and drug abuse.g. intense anger or difficulty controlling anger (e. impulsivity in at least two areas that are potentially self-damaging (e.. gestures or threats. and outbursts of intense anger may often lead to violence or behavioural explosions. perceived inappropriate. Instability of emotion. posttraumatic stress disorder. intense episodic dysphoria.g. associated with excessive efforts to avoid abandonment. irritability. behaviour and self-image has devastating and sometimes deadly consequences (75).6 CO MORBIDITY WITH BORDERLINE PERSONALITY DISORDER According to the literature BPD frequently co-exists with psychiatric illnesses including major depression (78). affective instability due to a marked reactivity of mood (e. or self-mutilating behaviour (70). obsessive-compulsive . chronic feelings of emptiness (72). and highlights the importance and need for a better understanding of BPD (77). 2. binge eating) (13). dysthymia (79). reckless driving. with BPD being the most commonly associated. 74). substance abuse. Welsh and Page (2000) who found that between 40%-65% of individuals who commit suicide meet criteria for a personality disorder. identity disturbance that is.3: Emotionally Unstable (Borderline) Personality Disorder. frequent displays of temper. a markedly and persistent unstable self-image or sense of self. indiscriminate/unprotected sex.g. and substance misuse (80). People with BPD can resort to self-destructive behaviours such as self-mutilation. Rizvi. or anxiety usually lasting a few hours and rarely more than a few days) (71). recurrent suicidal behaviour. The ability to plan may be minimal. social phobia.28 Dr Jenny Tohotoa to avoid real or imagined abandonment. serious over or under eating and suicide attempts to escape from emotional turmoil (76). Anorexia and bulimia nervosa (81). manic-depression. stress related paranoia or severe dissociative symptoms (73. together with affective instability. This is supported by Linehan. A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences. the ICD-10 classifies BPD as F60.
88). anxiety and despair (often complicated by shame). terror. shame. career plans. self-mutilation and sometimes suicide (89).7 DEFINITION OF BORDERLINE PERSONALITY DISORDER Authors see the person with BPDs’ life as displaying inconsistency in mood. reckless driving. People with BPD can exhibit a range of intense dysphoric affects—including rage. and panic disorder have also been identified co-existing with BPD (82). For people diagnosed with BPD. 2. experiences of dissociation. gender identity and values (40). greater liability in terms of anger and anxiety and oscillation between depression and anxiety are also associated with a diagnosis of BPD (91). feeling and behaviour are seen as adversely affected (86). overspending. minute to minute without appropriate environmental justification (92). 90).Struggling Striving Surviving 29 disorder. . identity. Intense mood reactivity. dissociative disorders and somatisation disorders (83-85). attitudes. Emotional equilibrium seems to be in constant jeopardy with unpredictable and impetuous. panic. all aspects of thought. sorrow. jobs. the ability to structure and organise tasks. aberrant sexual behaviour. humiliation embarrassment. makes completing tasks and following through difficult (17). it tends to steadily intensify and the sensation is so painful that people with BPD will search for relief from any means. values and thoughts. behaviour. and they seem unable to attain self-comfort. Access to memory is frequently hampered and whilst intelligence is not affected. usually by endorphin releasing behaviours that are ultimately self-destructive: for example binge eating. excitement. friendships. erratic and impulsive mood swings that can shift from hour to hour. trust. They found that people with BPD view themselves as victims of circumstances and seem to take little responsibility for their actions and resulting problems (36). jealousy and self-hate (87. Overvalued ideas of being bad. chronic feelings of emptiness and loneliness. terror. depression. Once dysphoria begins. Distortions in cognition and sense of self can lead to frequent changes in long-term goals. derealisation and non-delusional suspiciousness and ideas of reference can be identified in people with BPD (84. Judd and McGlashen (2003) proposed that the interaction between genetic and environmental influences combine to create a disorganised pattern of attachment for people with a BPD. substance abuse. Some people with BPD have experienced frequent dissociative experiences. depersonalization.
113) (105). The tumultuous quality of close relationships. Feelings of shame. performed by oneself. Research indicates that those who have been repeatedly abused are the most likely to inflict self-injury (106-108). Simeon et al. A person diagnosed with BPD often encounters problems with the need for intimacy and the reciprocal fear inherent in that need (98). People are seen as either good or evil. which is a consistent behaviour in people with BPD. 97). and they fear both engulfment and abandonment within relationships (100. Similarly Stone and Sias (2003) describe a complex group of behaviours in which there is “deliberate destruction or alteration of body tissue without conscious suicidal intent” (p. physically violent. 101). for example. there are no shades of gray (95). They fear both engulfment and abandonment within relationships and fluctuate between idealization and devaluation of others (94). 110). Splitting is believed to be associated with impossible binds a person experiences early in life (96). 2. accusations. suicide threats or attempts to make others feel guilty (26. has an important affect-regulating function that relieves the emotional distress they experience (109. leaving the BPD individual feeling lost and worthless (99).30 Dr Jenny Tohotoa Individuals with BPD are seen to experience an unstable self-concept that oscillates between feelings of inferiority and superiority and display ambivalent feelings toward others as well as themselves (93). (1992) refer to self-mutilation as “deliberate harm to one’s own body resulting in tissue damage. and purposeful (103). 221) (104). self-harming (102). The fear of abandonment appears to be related to difficulties of feeling emotionally connected to important people when they are physically absent. intentional.8 SELF-INJURY AND SUICIDALITY Alderman (1997) summarised self-injurious behaviour as an act done to oneself. The tension between this fear and need can cause feelings of rage and guilt expressed in self-punishment and anxiety that is relieved by displaying a range of acting out behaviours. without a conscious intent to die” (p. non-suicidal. humiliation. People with BPD seem to respond to attempted separation or distancing with rage. Self-mutilation. repeated break-ups and use of perceived maladaptive strategies that both anger and frighten others reflect the unstable nature of this disorder (97). frequent arguments. and . The process of idealizing and devaluing others and dividing people into separate “black and white” categories is called ‘splitting’.
threaten to carry it out and make multiple attempts (46. Holmes. Zlotnick and Costello (2002) suggested that persons with BPD experience emotions more intensely and have greater difficulty in controlling their affective responses (37). Cutting has been described as a re-enactment of childhood trauma. Mutilation is a way to alleviate stress.Struggling Striving Surviving 31 rage may pre-empt self-injurious behaviours and failure and pent up rage often precede the behavioural act of cutting (111).9 FACTORS IN THE DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER 2. and Lyons-Ruth. Hopelessness and seemingly impulsive aggression also increase suicidal behaviour (114). depression. McLane (1996) argued that self-mutilation allowed a trauma victim a “voice on the skin” when they otherwise feel silenced (113). numbness. internally falling apart) and unremitting crises vs.1 Psychological factors BPD is thought to arise from affective vulnerability as reflected by high sensitivity to emotional stimuli and high emotional intensity (117). 2. validation. 114). and a way to manage the emotional pain (106). more so than negative mood status (37. Reporting suicidal feelings does not necessarily equate with sincere life threatening intent. apparent competence (externally capable. 116). rejection. (2004) showed a strong association between BPD and insecure attachment and that individuals . Agrawal. These factors combine to create adults who are uncertain of the truth of their own feelings and who struggle with the dialects of vulnerability vs. a method of communicating the unspoken. Linehan (1997) believed people with BPD were raised in an environment in which their beliefs about themselves and their environment were continually devalued and invalidated (117).9. hyperactivity. Suicidal ideation is often a chronic state related to a variety of interpersonal factors (115). Affective instability is the BPD criterion most strongly associated with suicidal behaviours. inhibited grief (118. 119). People with BPD can have repetitive thoughts about suicide. Whilst many people with BPD contain their self-harming behaviours the alarming rates of completed suicide puts this group at high risk. Gunderson. and feelings of alienation and have been linked to self-mutilating behaviours particularly with rape or incest victims (112). active passivity (seeking a rescuer) vs. Yen.
3 Social factors “If we were to design a society most likely to create BPD among its citizens. sexual abuse and a chronic disruption of family life during early childhood (126). family history of mental illness.9. 2. In America. One theory attributes the release of endogenous opioids to self-harming behaviours which regulates the intrinsic opioid deficit (125). physical abuse. the common predictors of BPD were disrupted attachments. High levels of divorce.2 Biological factors Linehan (1997) theorised that people with BPDs are born with an innate biological tendency to react more intensely to lower levels of stress than others and to take longer to recover (117). libido and memory processing) (123). 2. loss of grandparents and stable accommodation cause difficulties for the child to develop stable role .32 Dr Jenny Tohotoa with BPD demonstrated a longing for intimacy and at the same time concern about dependency and rejection (120). Structural and functional neuro-imaging has revealed a dysfunctional network of brain regions that seem to mediate important aspects of BPD symptomatology (122).9. it is less likely that children will grow up in one home or be involved with just one family. the orbitofrontal and dorsolateral prefrontal cortex (controls concentration. presence of dysphoria. In adolescents. the hippocampus and the amygdala (involved with appetite. 39) (96). sleep. Australia or any of the other developed countries. 124). Symptoms with dysfunction in these areas of disinhibited impulsive aggression with disruption in emotional regulation and hyper-responsiveness of the hypothalamic-pituitary-adrenal axis are found in patients with BPD and history of childhood sexual abuse (sustained) (121. emotional responses and language) consists of the anterior cingulate cortex. Factors associated with poor outcomes include affective instability and increased lengths of previous hospitalizations. This dysfunctional frontolimbic network (controls judgement. our current American society would be almost ideal” (p. number of mother and father surrogates. presence of maternal psychopathology and history of parental brutality (121). planning and problem solving). grossly inappropriate parental behaviour. younger age when first in treatment. maternal rejection. maternal neglect.
Struggling Striving Surviving 33 models and have sufficient support systems (127). BPD develops in an atmosphere of neglect. Lack of parenting skills contributes to an inability to meet the developing child’s needs. . reinforces the neglect. Children are often raised by day-care workers or baby-sitters to accommodate parents working (128). and adds to the child’s sense of uselessness and worthlessness (129). whether intentional or not.
3. first developed by Glaser in 1978. interactions and observed behaviours.1 INTRODUCTION Whereas traditional research starts from specific research questions (usually phrased in tightly defined terms. The grounded theory method was chosen because it fulfilled the above criteria. Qualitative research methods are valuable in providing rich descriptions of complex phenomena.Chapter Three Chapter 3 describes the methodology undertaken for the research study. 34 . qualitative research initially deliberately avoids defining the research focus too tightly. It discusses the qualitative research method using grounded theory. illuminating the experience and interpretation of events by actors with widely differing stakes and roles. a phenomenon that had not been explored in depth previously from a qualitative perspective.2 QUALITATIVE RESEARCH Qualitative research is increasingly recognised as a legitimate and important methodological approach within the multidisciplinary field of public health (131). 3. events. conducting initial explorations to develop theories and moving toward explanations (131). Qualitative data provide depth and detail through direct quotation and careful description of situations. and often articulated in the form of testable hypotheses). the researcher enters the research context with a concern. tracking unique or unexpected events. or area of interest. and the researcher was able to obtain an insight into how people diagnosed with a BPD managed their life. that is felt to be worthy of study (130). giving voice to those whose views are rarely heard. Rather.
the researcher is encouraged not to separate the stages of design. Theoretical sampling strategies . links various data. Rather than starting with a research question that precedes any data collection. has implications for formal theory. 138). 3. The data analysis method used in grounded theory is termed the constant comparative method and this comparative analysis is a central feature (132. Analytic processes prompt discovery and theory development rather than verification of pre-existing theories (135). they aim to study things in their natural setting. As data analysis progresses. Understanding and meaning emerge from in-depth analysis of detailed descriptions and verbatim quotations (134). or interpret. It allows the researcher to identify patterns and relationships between these patterns by constantly comparing the emerging similarities or conversely the emerging differences identified within the data (135. recurs frequently. but to go backwards and forwards between the raw data and the process of conceptualisation. theoretical sampling techniques will also be used to broaden the sample to include people who have specific.Struggling Striving Surviving 35 Researchers who use qualitative methods seek a deeper truth. 3) (135). As the data are analysed the researcher searches for a core variable which will serve as the foundation for theory generation and has some of the following characteristics. Qualitative analysis seeks to capture the richness of people’s experience in their own terms. becomes more detailed and permits maximum variation (137). Thematic formulation can occur before. thereby making sense of the data throughout the period of data collection (133). enabling them to “remain sensitive to the data by being able to record events and detect happenings without first having them filtered through and squared with pre-existing hypotheses and biases” (p. different and broader types of experiences of BPD. data collection. and analysis.3 THE GROUNDED THEORY METHOD Traditional grounded theory asks of researchers that they enter the field of inquiry with as few predetermined thoughts as possible. phenomena in terms of the meanings people bring to them. 137). Initially purposeful sampling or selecting participants who have experience with the phenomenon under study will be used (135). has an explanatory function. and they use a holistic perspective that preserves the complexities of human behaviour (132). attempting to make sense of. during and after the initial process of data collection has occurred and focuses on the simultaneous conceptualisation and assessment of the similarities and differences in social interactions (136).
All of the participants had engaged in some form of therapy with either a clinical psychologist (4 participants) or were part of a behavioural change program (5 participants). Five participants were parents but only one participant had their children living with them. one lived with her husband and children and two participants lived with other. 3. Eight participants were female and one was male. unrelated people. The interviews were conducted at a mutually agreed place and time as free from interruptions as possible. Purposeful sampling was used to interview people who had experience in the phenomena under study. All the participants had experienced at least one presentation to hospital with BPD symptoms and all participants spoke English as their first language. most had previously worked in short term employment in a variety of occupations.4 DATA COLLECTION Data were collected using semi-structured open-ended interviews with people diagnosed with BPD. two had adult children and two had lost custody of their children. The sample population consisted of nine adult people who had been diagnosed with BPD with a mean age of 37 years.2 Research Interviews The questions for interview focused on what it was like to live with BPD. and commenced with the following question: “Tell me when you . Only one participant worked at the time of the interviews and that was as a teacher’s aide.4. 3. Once categories began to emerge the sampling was extended using theoretical sampling techniques to find participants who had different experiences of the phenomenon under study. Theoretical sampling included the inclusion of health professionals to give a different perspective on BPD.4. 3. Although the remaining eight participants were not working.36 Dr Jenny Tohotoa will be guided by the emerging codes and categories from completed interviews that have been analysed using the constant comparative method of analysis consistent with the grounded theory method (138). Five participants lived alone. one participant lived with both parents.1 Selection and characteristics of participants Participants were selected on the basis of having a diagnosis of BPD and a willingness to participate.
Initially data is transcribed verbatim and the typed text is read line by line for accuracy. It pulled together all the strands in order to explain the behavior under study. what type and in what circumstances they occurred. The nursing staff participants were interviewed using semi-structured and open-ended questions and focused on the nurse’s experience of caring for and treating people diagnosed with BPD in hospital. and represented the basic social psychological problem experienced by all the participants in this study. and stages of the process were identified. The researcher employed active listening skills affirming what the participants said by nodding and by encouraging remarks. The coding process of naming or labelling categories. 3.Struggling Striving Surviving 37 were first aware of having BPD”.e. The core category of being vulnerable emerged more frequently and was connected to many of the other categories that were emerging. The researcher examined how concepts occurred and how categories were related. Following the analysis of the data.5 DATA ANALYSIS: DATA CODING PROCEDURES Data analysis in GT follows a sequential process. Data analysis indicated that the core category was identified as being vulnerable. Three conditions influenced being vulnerable and striving for autonomy. 3.6 WRITING UP THE FINDINGS The writing up of the findings began when saturation of the data was obtained and the basic social psychological problem and the basic social psychological process were identified through the concepts and categories that emerged from the data during theoretical and selective coding. The properties of categories were explored i. The researcher later reviewed the interviews to see whether all questions were open-ended and whether any leading questions had unduly influenced the response of the participants. and properties then begins (139). Participants were then asked additional questions to explore the fullness of their experiences. The emerging core category was then verified through theoretical sampling and by asking participants to verify the findings. the conditions that influenced the basic . Further coding and analysis in this study revealed that the basic social psychological process of striving for autonomy was used by participants to manage the basic social psychological problem of being vulnerable.
7 TRUSTWORTHINESS. Theoretical sensitivity and an acute awareness of researcher bias allowed the researcher an opportunity to ensure credibility. • Italics denoted major conceptual terms. without changing meaning. The following points should be noted: • Each participant in this study received a code number. credibility and transferability of findings were ensured in this study by adhering closely to all stages of data collection. This ensured that researcher bias did not alter the data. 3. CREDIBILITY AND TRANSFERABILITY OF FINDINGS Trustworthiness. The findings regarding the categories were verified by some of the participants for validity of their experience and were discussed with other people who had experience with the phenomenon under study. direct quotations were used to illustrate the language and meaning of the participant’s experiences. analysis and write up outlined in the grounded theory method including the constant comparative method of analysis to ascertain that the categories were grounded in the data. for example P1. • Square brackets [ ] used in direct quotations indicated information which was added by the researcher to be grammatically correct. From the transcriptions. The trustworthiness. credibility and transferability of the data in this study were further ensured by selecting adult participants who had a diagnosis of BPD and the experience of managing their lives in Western Australia.38 Dr Jenny Tohotoa psychological problem and basic psychological process were identified. . trustworthiness and transferability of data by her awareness of nuances and inferred meaning.
physical. Reflecting on their sense of 39 . 4. leaving them continually vulnerable. distrust and insecurity. Having no validation for their feelings and being exposed to abuse left the participants struggling to connect in their dangerous world. It expresses the individuality and uniqueness of the person.1 STAGE ONE OF BEING VULNERABLE Self-identity is imperative to self worth and the ability to belong (140). Being damaged incorporated the participant’s experiences of neglect. maltreatment and neglect living in a dangerous world. Then at fifteen. (P3) Participants described both the physical and emotional dimensions of vulnerability. One participant in this study conceptualised it as: I grew up thinking “Oh the world’s a perfect place”. guilt. I moved out of home and bang [moved] straight into this world that I knew nothing about and I was lost in the world and because I was so vulnerable everyone took advantage of me. sexual abuse. maltreatment and abuse and the subsequent feelings that accompanied the damage. Not having a strong self-identity made life more difficult for the participants and kept them alienated. Their vulnerability was evident with feelings of fear.” Many of the participants experienced a combination of emotional.Chapter Four This chapter presents the basic social psychological problem experienced by people diagnosed with BPD living in Western Australia called “being vulnerable. Participants felt physically vulnerable due to being physically harmed and exposed to damage.
[and it makes me] very unsafe” (P2). even the home environment was physically threatening: “It was not a safe home environment at all” (P4).1 Communication Difficulties 2.1 Neglect and maltreatment 1.2 Overview of stage one of being vulnerable Figure 2: The basic social psychological problem:Being Vulnerable BEING VULNERABLE STAGE ONE Living in a dangerous world STAGE TWO Struggling to connect ASPECTS 1. Loss of Self ASPECTS 1.2 Sexual Abuse 1. they had no consistent rules to live by and this increased their emotional vulnerability to everyday life situations: “I always felt that things are never going to get better or if they get better they’re only going to get worse again” (P6). For others. Figure 1 identifies the links between the core category “being vulnerable “and the two stages participants experienced in their striving for autonomy.40 Dr Jenny Tohotoa being vulnerable they spoke of scenarios when they were physically unsafe: “Put me in a place where I don’t know who’s there [or] what’s going to happen. As the normal social rules did not apply to many of the participant’s home environment. Feeling Alienated 1. Being Damaged 1. 4.3 Physical Abuse 2. Fear of Abandonment .
The second aspect of living in a dangerous world was called “loss of self” and identified the loss of self-identity that occurred for participants as a result of the abuse and neglect they experienced.” Living in a dangerous world increased participants’ exposure to physical. They felt lost and scared and said that they lived in a dangerous world feeling unprotected and alone.Struggling Striving Surviving 41 The first stage. These . As the following participant explained: You lose yourself cos [because] everyone’s telling you how you should be. called living in a dangerous world. physical and mental abuse from infancy to adulthood. [and my] next memory was when I was school age” (P6). the sexual abuse by my grandfather starting in infancy. emotional. The perpetrators of this abuse were usually family members. participants experienced a loss of self-identity as the damage from the abuse continued to impact on their lives increasing their vulnerability. emotional and mental damage and participants often became caught up in a cycle of abuse furthering the damage. hurt and alone” (P5). The remaining participants whilst not experiencing sexual abuse were exposed to parental neglect which also left them feeling “vulnerable” and viewing the world as a dangerous place in which to live. living in a dangerous world consisted of two aspects. participants described a life involving sexual. you don’t know who you are.3 Living in a dangerous world The first stage of the basic social psychological problem of being vulnerable was called “living in a dangerous world. and then somebody’s telling you how you should be. Participants described different incest experiences of childhood sexual abuse initiated in infancy and for some continuing through adolescence. Most participants experienced sexual. Parental neglect and non-protective parenting contributed to the participant’s vulnerability. partners.” As one participant explained: “[I felt] lost. One participant described it as: “living in horror in a world of terror” (P6). As a result. The first aspect described participants’ exposure to neglect and abuse and was called “being damaged. In the first stage. but the participants also experienced abuse from family friends. You’re trying to play out this role that everybody expects you to be and it’s like fuck! Where am I in all of this? (P2) 4. physical and emotional abuse during their childhood and this abuse exacerbated their ongoing vulnerability by decreasing their self-confidence and sense of well-being. “My childhood was very traumatic. schoolteachers and strangers.
“All my family turned on me. “over protective” (P3). “You never knew what was going to happen next. I wasn’t a person.42 Dr Jenny Tohotoa experiences are consistent with those described by Zanarini. very young” (P2). you can’t think” (P2). I was scared for my life” (P3). Another participant described feeling confused. “unsafe” (P4). (b) Rejection: “With the sexual abuse. the people used to get angry with you and tell you that they were going to leave you and all that stuff when you were very.3. “confusing” (P8) and “filled with terror” (P6). Participants spoke of their difficulty with feeling rejected and confused: “I suppose it’s like your gut feeling [you know] you shouldn’t be treated in a certain way but then on the other hand your . Jovev and Jackson (2004) also described the danger people with BPD were exposed to (141). 1 Consequences of “Living in a dangerous world” (a) Confusion: Participants described how being unsafe resulted in confusion. Corroborating the sense of living in a dangerous world. humiliated and rejected by her father when she started developing secondary sexual characteristics at age nine: “My father stopped hugging me. Other participants spoke of how the stress and anxiety resulting from feeling vulnerable interfered with their thinking: “Your brain is so fried from the severe stress and trauma all the time. 4.. Participants described their childhood in a variety of ways: “strict and harsh” (P1). The normal structures that provide safety and feelings of security to others were often missing in participant’s social structure and their family and friends were not protective. I didn’t understand. I just know that I’m unsafe” (P7). Participants reported feeling in danger from those around them: “When I was growing up I was in danger. I was in danger and I was an animal that needed to stay as safe as they could from the predators” (P4). who found that 91% of their subjects [female inpatients of a mental health facility] reported having been abused and 92% reported being neglected. all my friends turned on me. Being vulnerable was enhanced by participants being unable to confide in anyone leaving them feeling unsafe: “I can’t tell them [my family] what I’m feeling. (1998) in a study on childhood abuse in patients with BPD. I can’t tell them. he avoided me like there was something wrong with me. before the age of 18 (97). it was unsafe” (P4). I didn’t know what I’d done wrong” (P8). et al.
(P2). my dad lost his job and my eldest brother committed suicide when I was sixteen. no domestic violence or stuff like that.4. it was hell” (P4). making it hard for the participant to make and/or keep friends: “The rule at my parent’s house was you’re not allowed to have friends around cos [because] if we stop being friends. in a word. I was very isolated and no-one was there for me” (P6). “I felt like a failure again. another participant felt isolated and controlled by her parent’s house rules and their paranoia. maltreatment and/or non-protective parenting. 4.4 Being damaged The first aspect of living in a dangerous world was called being damaged. For me it may have been the loss .4. which further increased participants’ vulnerability. and I just took [on board] everything that she said” (P9). Their lives had turned into hell: “hell.Struggling Striving Surviving 43 lens on the world is very confused and the fear of rejection huge” (P2). Similarly. Most of the participants experienced parental neglect. 4. I felt I didn’t belong in my marriage. “Mum was always yelling at me and putting me down.1. Both confusion and rejection led to feelings of insecurity and fears of abandonment. which meant that participants were harmed or injured during their childhood and/or adolescence. 4. couldn’t contribute” (P5). they’ll come back and steal everything they’ve [my parents had] worked for [over] the last forty years” (P3). The damage from the childhood abuse experienced by participants left them with a lasting sense of worthlessness that persisted for many into their adult years: “It’s like you haven’t got a right to anything because of the way you were treated when you were children.2 Damaged by loss of mother Family dynamics and loss of her mother at an early age probably affected the vulnerability of the following participant who explained: I didn’t have any abuse issues that I’m aware of. Damaged by being isolated: A tragic death within the family and subsequent breakdown of the family unit added to another participant’s sense of vulnerability and emotional neglect: “My family started to disintegrate. just like before.
. 4. However. she couldn’t be protective” (P2). I had malnutrition twice before [I was] five” (P2). Many participants left home at an early age.44 Dr Jenny Tohotoa of my mother when I was only 14 [years old]. I don’t know. Similarly. by myself a lot. this was also disastrous as participants were exploited and used outside the home environment as this participant explained: “I lived on the streets and in hostels and shit [other places] and lots of horrible stuff happened. some participants rationalised the neglect: “Mum was always very physically unwell and looking back. the way I was bought up being the only child. My dad was brought up without a father from the age of three so neither of them had any parenting skills” (P6). Neglect. mentally unstable as well” (P6). Even though the participants acknowledged the neglect and/or abuse they had experienced. (P7) The participants’ experience of being damaged was reflected in a study by Massie and Szajnberg (2006) who found that children responded to abuse and neglect with distortions of normal emotional development and they found that severe maltreatment in childhood would enduringly affect psychological growth (142). Having a mother with a mental illness left another participant also feeling unprotected and open to abuse: “Living with a mother with mental illness. I had lots of trauma.5 Neglect and Maltreatment The first component of being damaged was neglect and maltreatment and highlighted the non-protective parenting and care-giving most of the participants under study experienced during their childhood and adolescence. the inability of her parents to be nurturing was identified and accepted by the following participant: “She [mum] was brought up in an orphanage from the age of three [so] she had no guidelines [on parenting]. yeah I stayed in hostels til [until] I was about 17 [years of age]” (P1). failure to provide minimum care or long periods of emotional or physical absence is considered child abuse and participants described their anguish and distress at the lack of protection and understanding afforded them by their families: “Like you had nobody [to protect you] when you were a child cos [because] you’re mother was too ill to look after you. maybe it was that loss that triggered the self-harming [behaviours]. such as abandonment.
1 Consequences of neglect and maltreatment (a) Home was a dangerous place: Maltreatment incorporated emotional abuse and included any behaviour that was used to control the participants through the use of fear. [and he] beat me if he caught me talking to boys.Struggling Striving Surviving 45 4. and re-enforcing the experience of many of the participants under study. Weinberg & Gunderson (2008) suggested that neglect and maltreatment by both parents was a significant factor in the development of BPD (144). as this participant shared: “mum had a speed [drug] problem so she couldn’t help” (P1). I had no friends” (P8). Frankenburg. My mother was from a family of 13 and I don’t think that she was ever seen so how could she [see me]” (P7). The sense of feeling unheard and invisible was also felt by the following participant who stated: “People think I’m coping and don’t see underneath [they] don’t see the struggle” (P2).5. (b) Feeling of injustice and shame: The next participant described how overprotective parenting could be abusive and as neglectful as non-protective parenting: “Dad watched me all the time. the child was often neglected and therefore more vulnerable to parental abuse. sent my brothers to walk me to and from school. children may learn that it is unacceptable. a study by Cicchetti and Toth (2005) found that within a maltreating environment. In support of this participant’s experience. no-one cares what I feel” (P8). particularly negative ones (143). that experiences of abuse and neglect were significantly more common among BPD patients than among comparison groups (145). (c) Not being listened to and feeling invisible: Feeling invisible within the family home and acknowledging their parent’s inability to meet their needs led this participant to explain: “My parents just weren’t ever [able to give me what I needed]. Helgeland and Torgersen (2004) found in their study of causes for BPD. When the parent was struggling with drug abuse. how I feel isn’t important. or even dangerous to discuss feelings and emotions. Zanarini. . Reich. Fitzmaurice. Similarly. The difficulty in expressing their needs was highlighted by the next participant: “No-one listens to me. threatening. humiliation and verbal assault.
Sexual abuse also occurred outside of the family for many of the participants. rape and sodomy [anal intercourse]. siblings of the participants were also involved in the interfamilial abuse: “I had a sexually abusive childhood and my sister was abused [as well] with me” (P2). He thinks something happened when I was about five. Sexual abuse for participants took several forms: incest [sexual relations within the family]. He was babysitting me [while] my mum was going out with her friend and getting high [using drugs]” (P1). As often happens with incest. as another participant explained: “It was my Mum’s best friend’s son.6 Sexual abuse The second component of being damaged was called sexual abuse. Participants described different incest experiences of childhood sexual abuse initiated in infancy and for some continuing through adolescence. For the following participant the experience included both her sisters as well as herself: “At 11 [years of age] I was interfered with and raped by a workmate of my dad. he also interfered with my two sisters” (P6).6. molestation. but . (c) Feeling let down by parent: So called ostrich behaviour by her father added to the burden of disclosure and validation for one of the participants who stated: “Dad doesn’t want to know I was sexually abused. (b) Not being believed and accused of being at fault: There has traditionally been a great deal of suspicion and disbelief surrounding children’s allegations of sexual abuse and this was certainly the experience of one of the participants under study: “I was raped by this man when I was 13 and my mum didn’t believe me and then told me it was probably my fault anyway” (P8).46 Dr Jenny Tohotoa 4. Participants identified a father and/or a grandfather as the primary offenders.1 Consequences of sexual abuse: (a) No-one and nowhere is safe: One participant recalled: “My earliest memories of sexual abuse [were] by my grandfather [and] occurred when I was in nappies and continued until I was 11” (P6). including those who were also the victims of incest. Another participant related: “I was sexually abused by my father and my grandfather for many years” (P4). The perpetrators of sexual abuse outside the family involved friends of the family. 4. paedophilia [inappropriate sexual contact with children].
Participants experienced little or no reason to trust as their lives became more and more difficult for them: Not surprisingly. I was more open [vulnerable] to it” (P1). “It’s a very hard life. If I try to trust somebody then they’re going to hurt me. one of the legacies of sexual abuse was the lack of trust engendered from continually being betrayed by people purported to care and protect: “not knowing the boundaries I suppose of what is safe for me [is a problem]. Her uncle raped her when she was young and she was gang raped when she was seventeen” (P1). (e) Vulnerability to ongoing abuse: Sexual abuse also occurred at school by both a teacher and an older student in two separate incidents for the next participant. (f ) Lack of trust in others: Participants explained that because of ongoing sexual abuse they experienced a lack of trust and safety in their relationships with other people. I still have problems with it.Struggling Striving Surviving 47 he doesn’t know the extent of it” (P1). I don’t know how to trust” (P4). (d) Physical damage: The long-term effects of ongoing sexual abuse from a young age and ongoing sexual promiscuity were reflected by the next participant: “I’ve got a prolapsed uterus which is common and [like I’ve got] scarring as well from the sexual abuse and [the doctor said] that I’d never have kids” (P1). Another participant looking for sanctuary and safety experienced sexual abuse whilst an inpatient in a mental health facility: “I was put in there [mental health facility] at sixteen. She described: “I went into foster care when I was sixteen and a half [for my own protection] where I was [also] sexually abused” (P4). who described the ongoing vulnerability she experienced as a victim of sexual abuse: “My year six teacher was a paedophile and because I’d experienced sexual abuse when I was five. where there was further sexual abuse” (P6). Another participant shared how: “mum was probably abused by her father and that’s why she didn’t know how to protect me” (P8). Some participants grew up with parents who had experienced sexual abuse that compromised their ability to be an effective parent: “You’d think she’d [mum] have warned me. so I don’t trust anyone” (P4). and again in high school “[some guy from school] raped me” (P1). . One of the participants was removed from her home and placed in foster care for safety only to experience the same sexually abusive environment as she had come from. I mean I didn’t know how to deal with people. she went through it herself.
they’re more of an acquaintance” (P5). They found that the awful burden for the patient is to tolerate the intolerable. but I have very few friends (P9). nor having the energy to maintain or sustain a close friendship: “I’m just coping with myself and having close friends I find difficult” (P6). other participants reported the ongoing difficulties they experienced with relationships: “I’ve always dated women from abusive backgrounds” (P5). and the difficulty maintaining relationships: “I’m avoiding relationships. They talked about not being able to commit. well. The invalidating environment that the participants experienced during their abusive childhood led to their inability to appropriately apportion blame and subsequently to a sense of self-blame: “If anybody was at fault it must be me cos [because] there wasn’t a question of adults being wrong and if there was anything sexual going on then it must be my fault”(P6). Similarly. As this participant explained: “I’m scared of relationships and still fear adult shouting and laughing” (P6). Supporting participants’ expressed sense of emptiness and vulnerability was a study of the vulnerabilities of children from a sexually abusive childhood by Hooper and Koprowska (2004). of being recognised for themselves as individuals. (i) Loneliness: Another participant explained how loneliness was her Achilles heel: “I just hate to be alone. only acquaintances: “I don’t see that I have any solid friends. (j) Can’t identify what is right or wrong and who is to blame: Participants in this study expressed their lack of feeling validated. (h) Difficulties with relationships: Another participant acknowledged that: “interpersonal relationships. I just haven’t got the mental energy for it” (P6). the sheer pain related to feelings of emptiness (146).48 Dr Jenny Tohotoa (g) Fear: Participants described a world of confusion and rejection as they discussed their concerns with interpersonal relationships and highlighted the difficulties related to fear and trust issues. and the confusion that engendered: “You grow up with this total confusion of what is right and what is wrong. having emotions and opinions. One of the consequences of not being able to trust is the difficulty maintaining meaningful relationships and an integral sense of emptiness. there’s still a big distance between me and other people” (P4). . The participants under study highlighted this legacy when they described a life with no friends. you’re very confused at whether you’re right to be angry or not [at the sexual abuse]” (P2).
that the belt was coming” (P4). (b) Fear and lack of safety: Fear and lack of safety resulting from lack of trust were major concerns for the participants in this study who were victims of sexual and physical abuse. Another participant related an ongoing environment of physical abuse from childhood through her married years and then from her own children: “I’m beaten around everywhere. pretty horrific kind of circumstances to grow up in. never safe” (P4). She found that adult survivors of childhood sexual abuse are at increased vulnerability to violent partners in adulthood (147). Another participant explained: “You never knew what was going to happen next. fear and vulnerability to abuse left most participants unsure of themselves and without a strong sense of self-identity.Struggling Striving Surviving 49 4. Similarly. the abusers were most frequently the participants’ partners as this participant shared: “I left my boyfriend’s [like] we had a bit [of ] domestic violence stuff. verbally and emotionally abused by my ex [husband].1 Consequences of physical abuse (a) Regarding violence as normal: Both parents were involved in the next participant’s abuse and contributed to her lifelong safety issues: “I was physically abused by both my mother and my father. it seems to be part of our relationship” (P1). .7. As one participant related: “I was never. The following participant described a violent incident with her father: “Dad ended up going psycho [losing his temper] and punching me in the head” (P3). verbally. research on trauma and recovery by Herman (1994) reflected the previous participant’s experience. If the physical abuse continued into adulthood.7 Physical abuse Many of the participants were the subject of physical abuse and the abusers were usually family members. then your own children have been abusive to you. emotionally. I thought I’d die” (P9). You knew if you heard the cupboard door open. it was unsafe” (P2). and another participant related a similar incident that involved her mother: “She just wouldn’t stop hitting me. physically” (P2). a lack of trust. All these consequences contributed to being vulnerable however. 4.
The loss of self follows as the result of being damaged. I have no me” (P8). Having little or no positive affirmation and validation from their parents and caregivers left many of the participants without a sense of identity or self: “I’ve never been myself ” (P5) (b) Depending too much on other people’s feelings and thoughts: One participant explained: “It’s like you don’t feel you can contribute that you’re. I suppose. maybe I am what she [mother] says I am” (P2). Not having a strong sense of self most of the participants struggled with a poor self-image re-iterated by one participant: “You had this really poor self-image” (P4). I don’t really want to be me. 4. you know. worthless” (P6). Not being grounded and unaware of her surroundings led the following participant to experience a sense of “[being] always inside my head” (P3). Not having a strong sense of self led this participant to blend and transform by acting to meet others needs as required: “I just do or say what I think people want. cos [because] I don’t know who me is” (P4). “Well. another participant related their difficulty in being themselves. a sense of inner self and some acknowledgement of one’s role commitments and views of oneself by the broader community (148).1 Consequences of loss of self (a) Unable to identify themselves: Participants who had experienced an abusive childhood and found themselves in an ongoing dangerous world. Again. “I didn’t know who I was cos [because] I didn’t want to be who I was” (P3). talked about losing themselves: “It’s a family pattern: we lose everything until we come down to nothing and even hardly yourself in the end” (P2). Another participant shared an experience from childhood that reflected the vulnerable nature of her self-image: I can remember back in primary school.8 Loss of self The second aspect of being damaged was loss of self.50 Dr Jenny Tohotoa 4. a sense of personal sameness or continuity over time and across situations. The participants expressed a sense of confusion with their self-identity: “I don’t know who I am. In the 1960s Erikson (1963) defined identity as having role commitments. [like] looking at myself in the mirror and liking myself and the second someone said . anything to be accepted.8.
. the canaries on the shoulder of the miners. (e) Becoming hyper vigilant: Describing herself metaphorically. no one else can tell us how we should be feeling” (P3). the following participant said: “We’re the canaries. hyper-alert to the nuances and the little things that go on” (P2). not being seen: “It’s like. they’re just not listening” (P2). (P3) Not having a strong sense of individual identity and self was highlighted by several of the participants who used the plural to describe themselves: “Only we know how we feel when we wake up.Struggling Striving Surviving 51 something bad to me. (c) Health professionals do not recognise the whole person: Participants also experienced a loss of self in relation to the interactions with health professionals: “They don’t see the real me. I didn’t know why I relied so much on other people’s feelings and thoughts. it’s like the iceberg” (P2). You know what kind of situations I’ve been in and what’s actually happened to me. I’d hate myself. we know when something’s not right we are hyper vigilant. (d) Being invisible: The following participant shared her experience of not being heard. they’re [health professionals] looking at all I do wrong but not at what’s actually happened to me. we are more than what you see. They’re not listening.
watching how to do it [have friends] and it just didn’t happen. 52 .Chapter Five 5. They described feelings of loneliness and a sense of isolation from others that maintained their vulnerability to being unacceptable which further heightened their lack of self-identity and self-esteem. There were two aspects to this stage and they were entitled “feeling alienated”. and the difficulty with trusting other people. Being unable to articulate their needs effectively and discouraged from being self-confident left most participants feeling worthless and vulnerable to feelings of depression and self-harm with suicidal ideation. it was something to do with me” (P8). and poor self-image. where participants described their difficulty in connecting and establishing lasting relationships and “fear of abandonment” where the participants discussed their fear of rejection and their wanting to belong. As a consequence of the abuse participants were left to experience feelings of abandonment. One participant provided this example: “I was always looking from the outside. Their experiences of abandonment left them feeling rejected and apprehensive not understanding what was happening and trying to survive their abusive childhood. The second stage encompassed the difficulty participants’ experienced in interpersonal relationships along with their experiences of feeling different. participants then entered the second stage of the basic social psychological problem of being vulnerable called “struggling to connect”. emptiness and insecurity displaying low self-esteem.1 STAGE TWO OF BEING VULNERABLE: STRUGGLING TO CONNECT After experiencing damage from living in a dangerous world. Struggling to connect led to participants feeling alienated and different from others.
[in] a series of unsuccessful relationships “(P7). (P1) . From a young age.’ it was so weird. 5. discrimination and sense of blame she experienced at high school following the disclosure of abuse from a paedophile in primary school: When I got to year eight in high school. Due to this lack of connection they also felt vulnerable. most of the participants in this study experienced episodes of being out of control.1 Consequences of feeling alienated (a) Not being able to express themselves for fear of reprisals or punishment: One participant talked about the alienation. As a consequence struggling to connect explored the sense of alienation many of the participants suffered and the resulting loss of self-esteem and self-confidence. One of the reasons participants gave for struggling to connect was not being seen by others as an individual with a separate identity. you’re a big blot of ink that’s splattered everywhere that nobody wants” (P2). [and] the male teachers would go ‘[my name] . struggling with relationships. depression and self-harming thoughts. Being vulnerable in this way created a struggle to connect: “turmoil. The ongoing problems for the participants included their lack of confidence and self-worth. 5. unable to trust those people who were most significant in their lives and whom they relied on for protection and nurturing. feeling different and being unable to identify with those around you. the fact that I had accused my year six teacher of being a paedophile got around. This was explained by the next participant who stated: “You haven’t had a role model from any parents and you’ve never had any love. being: “seen as being the loony” (P2). struggling to connect. needs and rights.” She went on to express her derogatory sense of self and the associated sense of worthlessness: “What a blob you are on the bloody page. get away from her. began when participants experienced a sense of being different and feelings of alienation. quick get away from her. leading to suicidal and self-harming thinking in some cases.Struggling Striving Surviving 53 The second stage. feeling lost and hopeless. Another reason given by the participants for struggling to connect included poor role modelling from parents.2.2 Feeling alienated The first aspect of struggling to connect was called feeling alienated. Alienation occurred as a result of feeling isolated.
another participant related the difficulty with connecting to others: “I don’t remember ever having girlfriends. Similarly. but everyone else around you” (P4). If my psychiatrist knew half the stuff that’s going on for me. (e) Unable to connect: Participants talked about feeling and being different from other people with the result that: “people [were] constantly laughing at me cos [because] I’d think of things in a totally different way from how the rest of the world does.54 Dr Jenny Tohotoa (b) Harbouring resentment: Many participants described controlling environments that did not allow the child to develop their own sense of self and personal beliefs. Feeling misunderstood was integral to feeling different. I knew there was something different with me. as this participant reported: “It’s been hard to get people to really understand. I felt different. This participant explained: “You’re constantly having layers and layers of shame and guilt and grief being put down and more grief and more grief on top of that you never get rid of it” (P2). The way my mind processes things is totally different to somebody else’s” (P3). but promoted a dictatorial. I reckon they’d lock me up forever” (P2). authoritarian milieu that added to their alienation and vulnerability. all the time an outsider” (P2). As this participant shared: “It’s not only yourself you hurt with this illness. Having no voice and no encouragement to have an opinion led many of the participants struggling to effectively communicate and left them even more alienated . [I] felt like an outsider. The more I cried the more it hurt” (P4). (c) Guilt and shame: Participants talked about the guilt and responsibility they felt towards their family and others affected by their BPD. leaving her with diminished support and an increased sense of alienation and apprehension: “You’re too ashamed to say anything to anybody and you daren’t tell your psychiatrist. Several participants identified their sense of shame and guilt related to intense grief feelings which added to their poor self-esteem and alienation. (d) Not able to get appropriate help: The ramifications of shame and fear were exposed by the next participant unable to confide in her doctor. I just didn’t know what” (P8). Another expressed: “A lot of guilt came about with the sexual abuse and I was ashamed and [had] a lot of unhappiness” (P6). and always feeling alone. that I wasn’t allowed to show emotion. As this participant reflected: “I was taught that I wasn’t allowed to cry. and again reflected their sense of vulnerability.
Several participants talked about being black and white in their thinking with no room to manoeuvre: “I’m very much a black and white thinker. Participants also described feeling illogical and extreme: “The whole point of my life has been the extreme. Black and white thinking means no compromise.1 Consequences of communication difficulties (a) Unable to express emotions: Participants talked about the communication problems within the family and expressing emotions was often difficult which added further to their struggle for autonomy and validation: “My family never really talked about emotions. all or nothing. very much. . “It’s always been all or nothing. and the choices are in the grey area” (P5). with the black and white there is no grey. no in between.3 Communication difficulties A component of feeling alienated was called communication difficulties. (b) Unable to compromise: Participants also spoke of the inability to compromise their concrete patterns of thinking and the difficulty they experienced with the black and white thinking. This pattern of behaviour continued from childhood into the participant’s adulthood and into her marriage. totally illogical” (P5). very black and white” (P8). She related that: “We don’t talk a lot about our emotions and my husband isn’t one to talk about our relationship or how we feel” (P7). Lack of communication in the family and no arena for shared expression was identified as a major source of distress and frustration for the participants. no gray in between and is a feature of BPD: “They talk about people with BPD being black and white” (P2).3. It’s all got to be right or it’s all wrong” (P4). Another participant shared her concerns about her parent’s lack of communicating and the negative affect that had on her: “mum and dad [like] never got on well and they still don’t now and don’t talk to this day.Struggling Striving Surviving 55 5. As this participant explained: “communication in our family was non-existent” (P6). black and white thinking. which is one of the things that shit me” (P1). This made life difficult for participants who had difficulties with making choices “sometimes it’s too hard to see the choices. 5. expressing any emotions was never encouraged” (P7).
lots of things happening all piling up and having no supportive family. so many people dying in the family. like my brother” (P6).4 Fear of abandonment The second aspect of struggling to connect was called fear of abandonment and a major aspect of being vulnerable. never got to know anyone” (P6). I had no sense of security and stability. Fear of abandonment is the force behind the need to belong and have identity. another participant related a scenario that left her feeling insecure and heightened her sense of isolation from others: “I’d been renting and moved probably 18 times by that stage. She just couldn’t handle having me around because she was worried about me suiciding.4.1 Consequences of fear of abandonment (a) A fear of abandonment based on reality: The following participant related the experience of abandonment by her family because of their inability to cope with her suicidal thoughts and self-harming: “I was asked to leave home and my dad took me to the YWCA [shelter]. no stability”(P2). As this participant stated: “I haven’t found stability or structure” (P5). suicides.56 Dr Jenny Tohotoa 5. Belonging is an important part of maintaining and affirming oneself. Having no stability or security of lifestyle was a feature for participants who described an itinerant life style over many years: “I had five moves in my first year of life. I’ve had 53 moves in 60 years. Constantly moving house made maintaining relationships very difficult and left participants with an ongoing sense of alienation and abandonment. (b) No stability and increased isolation: Another participant cited the multiple losses of people and support that contributed to a sense of abandonment: “I lost so many things. so yeah. Participants spoke of the difficulty in finding stability and this added to their sense of isolation and lack of connection. 5. Similarly. [husband] it was shocking” (P2). cos [because] it was just intolerable for mum. I remember sometimes moving every three weeks with my ex. (c) Never belonging and wanting acceptance: Attempting to please highlighted the fragile self-esteem of one participant who stated: “I’ve never told them [health professionals] the truth cos [because] if I tell . Abandonment issues and feelings of instability and insecurity were highlighted by most participants in this study.
Being acceptable and having approval was identified as being very important to several of the participants and they discussed their need to belong and the desperate measures they took to achieve that approval and belonging: It feels good to be accepted for that little while.Struggling Striving Surviving 57 them the truth they’re going to think that I’m no good and they’re not going to like me: It’s a really big issue” (P4). . If that means not paying my bills. (P4) Another participant talked about never belonging and the sense of self-hate and futility that engendered: “I’ve always hated myself because I never felt I belonged anywhere. so I’ll do whatever it takes. if it means not eating for a week so I can have the money [which I don’t have to spend] to spend on somebody. I’ve always felt that I’m just a reaction” (P6). I will do it so I can be accepted. Belonging and acceptance are intertwined with self-esteem and self-identity and negate the feelings of abandonment and alienation.
Another participant shared: “I realise all my running away doesn’t do me any good but it allows me to survive” (P5). I manipulate people to get what I want” (P1). The methods used by the participants in their quest for autonomy initially involved a ceaseless struggle to survive: “I simply learnt to shut down. Being diagnosed with BPD usually occurred in the context of a serious self-harming attempt that required hospitalization and 58 . Analysis of data revealed that the basic social psychological process of striving for autonomy consisted of three stages. dangerous world in which they lived. and at the same time find means to escape the abusive. I’m real pretty hey. Stage two followed on from stage one and was called “finding answers”. dangerous world which found them vulnerable. It involved a turning point in participants’ lives that provided them with the impetus to look for meaning and a way of changing their lives. Participants sought answers to make sense of their life experiences and strove to become independent and self-determined. p. I’m a beautiful little sociopath. Alcohol and drug abuse featured as a way of coping and escaping for many of the participants and reflected the difficulty they experienced in their struggle for autonomy.Chapter Six 6. and the behaviours employed by them to survive. The first stage “learning to survive” identified the participant’s response to the abusive. Survival had to be accomplished and overrode any other possible negative consequences. One participant explained: “I used my face. 1978. and most people just buy me what I want. 97) people diagnosed with BPD engaged in to overcome and manage their experience of being vulnerable. 1 AN OVERVIEW OF STRIVING FOR AUTONOMY The basic social psychological process of striving for autonomy was the “pattern of behaviour” (Glaser. it taught me that there were certain things you had to do to survive” (P4).
Figure 3: The basic social psychological process: Striving for Autonomy THE BASIC SOCIAL PSYCHOLOGICAL PROCESS: STRIVING FOR AUTONOMY STAGE ONE Learning to survive Aspects: 1 Reacting to being damaged 2 Ambivalence with living 3 Seeking safety STAGE TWO Finding answers Aspects: 1. Engaging practical measures 3.Struggling Striving Surviving 59 was part of the turning point for most of the participants under study: “The fact that I know a name for my illness makes it easier for me to deal with” (P3). When this happened. At the time of being interviewed for this study. participants entered the third and final stage of the basic social psychological process of striving for autonomy that was called “taking more control”. most participants had experienced all three stages of the basic social psychological process of striving for autonomy (see figure 2). Acquiring new skills . Gaining insight STAGE THREE Taking more control Aspects: 1. Moving forward 2. Turning point 2.
(P5) . (P4) As despair increased. I wouldn’t have to suffer anymore and it would be over. When I am highly distressed I can do loads and then still not be satisfied” (P9). if that means blowing up in somebody’s face. finished. Recognising the dangers of being vulnerable and the threats to survival was paramount. “I can’t just cut myself once and stop there. as this participant explained: “It’s all related to what I learnt as a child and how I learnt to cope and survive in the circumstances I was in” (P4).2 STAGE ONE: LEARNING TO SURVIVE 6. if that means running. The behaviours involved included some form of escape to help them cope with and endure the horror and terror of their lives. Participants explained that their self-harming could on occasions escalate to suicidal ideation and intent and it was often an impulsive act as the following participant mused: I don’t have suicidal tendencies. it’s about surviving life. The thought [that] it would be so easy if I could just end it all now. it’s about getting through the best you can and doing whatever it takes to survive it” (P4). participants used self-harming behaviours.2. Participants talked about their initial steps towards autonomy that involved just trying to survive and identified surviving as a way of life: “From my perspective.60 Dr Jenny Tohotoa 6. I still have that on the back burner. Data analysis identified a wide range of behaviours and coping mechanisms that participants put into practice in their quest to survive a dangerous. if that means hiding. I usually do at least a dozen or so. One participant encapsulated the desperation involved with surviving when she stated: If that means creating havoc. if that means [you know] some really unhelpful coping kind of skills. kaput [finished].1 Introduction Stage one of the basic social psychological process striving for autonomy was called learning to survive. unsafe world by escaping. then that’s what you do cos [because] that’s what you have to do to survive. it isn’t about creating a life or living it.
6.3 Reacting to being damaged The first aspect of learning to survive was called reacting to the damage and highlighted participants’ methods of response to an abusive childhood. or to escape the traumatic memories of their childhood. like sexual abuse. physical and mental pain.1 Adaptive behaviours Participants acted in the only way possible. learning to survive of striving for autonomy were a) reacting to the damage b) ambivalence with living and c) seeking safety. Two components of reacting to the damage were identified and these were: a) adaptive behaviours b) self-harming behaviours. by moving away mentally and emotionally from that situation: the dissociative process was a means of survival and a way to cope with trauma. 6. Each of the aspects will now be presented. somehow or another.Struggling Striving Surviving 61 Self-harming and suicidal ideation and intent were described by participants as a means of escaping their emotional. illicit and prescription drugs. which allowed them to survive physically painful situations. then I would make it go my way.3. and risk taking behaviours involving promiscuity and reckless driving as ways of dealing with the complexities of living. Some of the participants experienced a sense of depersonalization and frequent episodes of dissociation. In order to still maintain safety some participants searched for containment in hospital. I’d do what it takes” (P4). They perfectly adapted to the damaging environment by trying to survive and struggled to overcome their vulnerability in a dangerous world. Participants used these behaviours in an endeavour to get their needs met. Participants were searching for an escape while at the same time wanting safety and security. all of the participants in this study had experienced abuse or neglect and the three aspects of stage one. (a) Manipulation: “If something wasn’t going my way. The ongoing suffering of participants was reflected in a variety of behaviours highlighting the difficulty they had in caring for themselves and developing intimate relationships. Participants identified destructive escaping mechanisms such as alcohol. Another participant talked about manipulation being a survival . In summary.
The use of sexual favours as a means to gain closeness reflected the participant’s survival skills which was an essential first element of gaining autonomy. The following participant’s experience also highlighted the dangers of unsafe sexual practices and being vulnerable: “I got pregnant three times in two years and I’ve had three abortions” (P1). doing whatever it takes” (P8). (b) Promiscuity: Participants discussed using sex to make them feel wanted and desirable. particularly at [mental health facility] with lots of alcohol and drugs. manipulating people to get what I want. although failed to increase their sense of autonomy. Sexual promiscuity without any intimacy reflected the vulnerability of the participants who were searching for a way to connect with others but found only transient relationships with no commitment or emotional involvement: “I was pretty promiscuous sexually as a teenager. anything to escape and survive” (P6). In this context. I never even liked the sex” (P6). Manipulating the environment (metaphorically speaking) helped the following participant escape: “I’ve never drowned [not been able to survive] before cos [because] I’ve always got out of the water [found a solution] before that happened” (P5). and helped them to survive. This theme of promiscuity was re-iterated by the following participant and illustrated her ongoing vulnerability and emptiness: “I was pretty promiscuous sexually as a teenager. I really didn’t care who they were” (P8). be anyone but you” (P4). I just didn’t care. I was looking for someone to care for me. I sped around in the Ford on the Great Eastern Highway bypass at 180 km per hour” .62 Dr Jenny Tohotoa technique when she stated: “That’s how I’ve survived. but others at high risk of harm: “I took the car and all the money in the account and went to my first brothel. These behaviours were utilised to overcome the basic social psychological problem of being vulnerable. manipulation meant managing a situation or person to one’s own advantage as this participant described: “I would manipulate any situation and I still can manipulate any situation to suit me” (P4). which not only put himself. pretending and acting were used by some participants in order to achieve their needs: “You learn that you can act according to how anyone wants you to. Like manipulation. “I put out for anyone who would be nice to me. (c) Recklessness: One participant resorted to recklessness as a way of coping after an argument with his wife.
including keeping a memory but no feeling. Another participant recalled: . It’s really weird” (P8). He said: I put my car in the river. it profoundly affected those who did experience dissociation. (d) Dissociation: Some participants reacted to their childhood abuse with an unconscious escape into dissociation and even though it was not experienced by all participants. the participant stated: “It didn’t occur to me. Another good example of escaping and surviving. the same participant put his car into the river. I had all my stuff in the back. that you might as well be dead. They said ‘we used to see him saying all these things to you and smacking you in the head and doing all these horrible things to you and you’d just be expressionless.Struggling Striving Surviving 63 (P5). cos [because] I think that’s how I survived? (P2) The same participant described her sense of being dead emotionally. existing” (P2). Chefetz (2005) found that a child is more likely to develop dissociation when subjected to sexual abuse by a family member or other person whom the child trusts and/ or upon whom the child is dependent. let it go. not able to feel anything: “You go so dead. by simply blocking out all memory of the event (90). As a response to increasing stress and a decreasing tolerance for responsibility. I didn’t want any more responsibility. took the handbrake off. documents and stuff. The following participant described one of her experiences of dissociation in the context of physical abuse: People who knew me with my ex.’ So it probably didn’t. you’re just dead. basically. put it into drive. it was like it didn’t register. The human psyche can distance itself from the trauma in any number of ways. (P5) When asked about possible alternatives like selling the car. my mobile phone. ‘shit she’s got that blank expression on her face’. you are dead. [husband] years later would tell me. which is reinforced by the participants under study (149). I’m really impulsive like that” (P5). my briefcase. you’re just walking. or partitioning off feelings into compartments inside the mind. it’s like there is only one way to go. Several participants in this current study experienced dissociation whilst self-harming: “I never feel pain at the time and really have no memory of doing it. Travelled down to Guilford boat ramp. did it.
with a feeling of detachment from themselves.4 Self-harming behaviour The second component of reacting to the damage was self-harming behaviours and involved the behaviours that the participants employed to relieve their distress or that brought them to the notice of mental health professionals for safety. The impact of depression and fluctuating moods on an already vulnerable psyche increased the self-harming potential for many of the participants under study and re-enforced the difficulty of living in a dangerous world. 6. the burden of trying to survive increased and their suicidal ideation and intent became more acute. which is what I tend to go into when I am doing some form of self-harm. specifically related to cutting (69. I can’t move. The ongoing suffering of people with BPD and the participants in particular is reflected in their self-harming behaviours that paint a graphic picture of reacting to the damage with loneliness. . (e) Depersonalisation: Participants also described being depersonalized. family violence. just freeze like I’m frozen. For those participants who experienced flashbacks and other symptoms of posttraumatic shock. Many of the participants used self-harming behaviours in their attempts to either die or be free of their emotional pain and emptiness or to escape their despair. The same participant described what happened when she experienced flashbacks [memories of her abusive childhood]: “Sometimes I’ll just freeze. a feeling of being disorientated. These methods of coping with abuse memories and attempts to connect to people allowed them to survive in a continuing vulnerability. what’s happening” (P2). I’d shaved it all off and I had a slashed up arm (P4). I get this feeling [like] where are we.64 Dr Jenny Tohotoa When you come out of this dissociative state. you’re feeling kind of bad. 85). people think I’m crazy” (P2). As the following participant related: “I can be driving along in the car and be parked at traffic lights and all of a sudden it’s like. loss of a parent or serious childhood illness may contribute to self-harming behaviour. I mean I had no hair left. Dissociation has been shown to link the experience of childhood abuse with subsequent self-harming behavior. that is. and deep depression. unhappiness. can’t explain. they experienced a loss of time. emptiness. Childhood experiences of physical and or sexual abuse.
You know if anything’s crap all you have to do is take something else and go to sleep” (P1). discomfort. sometimes reacting to the damage this way. 6.2 Alcohol use The sense of being vulnerable with regards to feeling inadequate and not feeling as if they belonged left many participants vulnerable to the lure of alcohol-enhanced confidence: “When I went out I was always in the spotlight if I was pissed. I’m going to drink more”(P1).Struggling Striving Surviving 65 6. I thought they would make me more mature. They made me feel important. Likewise. [like] he was injecting and I wasn’t and he introduced it to me. led them to engage in risk taking behaviours that increased their basic social psychological problem of being vulnerable: “I was [like] intravenously using speed and any other substances I could get my hands on. anxiety and their negative mood. they made me feel special” (P3). The appeal of drugs and other behaviours in soothing. so I was always pissed. It was the only time I felt part of life” (P8). If I go to a party and people are using a lot of speed or ecstasy and I can see them [then] I want that feeling and damn.4. I thought they would make me more popular. it gave me space” (P1). distracting and escaping is apparent and powerful. other participants reacting to the damage used illicit drugs because it gave them something to share with others: “We were both using crystal meth [methamphetamine] heavily.1 Drug use The use and subsequent abuse of drugs featured as a means of reacting to the damage for several of the participants. However. It became something we could share” (P1). although giving participants space. Another participant described alcohol as a lifesaver.4. Still another participant described the place alcohol had in her life with regards to the feeling of wanting to belong: “I guess I binge drink. as this participant explained: “The good feelings are chemically induced so you know when you’re going to get them. so no surprises. another participant identified drug use as a way to belong and counteract the loss of self despite other problems it created in her life: “I thought they [drugs] would make me more socially acceptable. She identified the role of alcohol in her life as the safest option for . Participants’ perceived that drugs offered them a way of reacting to the damage as the drugs provided relief and blocked out sensations of pain. Drugs were often used in reaction to the damage brought on by feeling bad and to opt out. However.
3 Physical abuse When all the measures to react to the damage failed to significantly overcome being vulnerable participants sank into despair and desolation. “Like I want some attention here and I need to do something to get that attention: This is what I’m going to do.4. go to the toilets and bang my head. and I lashed out at myself constantly” (P6). 6. If I hadn’t been doing that I would have been doing something more fatal” (P2). “Basically. well he doesn’t even know what’s wrong with me so I’m just going to take an overdose.66 Dr Jenny Tohotoa reacting to the damage: “I didn’t give a toss what people thought about my alcohol. I didn’t even know what I was doing” (P6). Feeling unheard and frustrated with life in general also contributed: I got really upset and started to cut all my hair off in the bathroom [it was down to my waist] and I was lying on the floor with the scissors in my hand and my hair all over the floor and in the basin.4. (P1) . used to go out from the class. I didn’t care. the alcohol.4 Attention seeking One of reasons for the desperate self-harming reactions to the damage was to gain some attention so that their plight might have been revealed to somebody. I don’t know why” (P6). he (Dad) walks in and cleans up all the hair. Another participant identified the cathartic use of alcohol: “I go out and have a bottle of champagne to myself and get real giggly and have a real good headache and go to sleep and then I’ll wake up in the morning and I’ll feel vented and purged” (P1). I just lived from reaction to action to reaction. Then he just left and I was like “hello” [I am] cry[ing] out for fucking help here. and took a whole bunch of pills. “I never thought of any consequences. I didn’t care cos [because] it saved my life. take a whole pile of pills” (P4). for the first 20 years. In their continual suffering they did not know what to do and engaged in desperate measures. The following participant talked about the continuing pattern of self-harming behaviour throughout her childhood and adolescence: “I used to bang my head against the wall at school. 6. So then I went into the [medicine] cupboard and thought.
I have lost all hope. it’s only a thought”. self-hatred. When I’m self-injuring. stubbornness and self-damaging impulses. (P7) The resulting futility and despair left participants in limbo: “Through all my [self-harming] attempts I’ve gone from one extreme of wanting to die to I can’t die. deliberate self-harm with superficial cutting and overdosing were often the behaviours that brought participants in contact with mental health professionals. Self-injury helps me get through the moment” (p. participants in this study argued that the self-harming behaviour saved their life despite the fact that most people would have difficulty understanding their actions: “It might have been that people would have seen all the other self harming things you do as a really peculiar way of coping but what they need to understand is that it gives us life” (P2). Contradicting this supposition is the general consensus from a wide range of literature that anger is the central feature in the precipitation of suicidal and other self-harming behaviours in people with personality disorder (153. Oldham and Morris (1990) in their study on personality portraits found that individuals with BPD struggle with despondency. They are desperate. you’ll be ok. Suicide is a permanent exit. despondency. fury. I’ve tried so many times therefore what’s the point of trying again. I want to die. The concept of self-harming as positive rather than negative was reiterated in “A Bright Red Scream” by Strong (1999) which highlighted the affirming aspect of self-mutilation in contrast to the perceived negative of suicide: “If I’m suicidal. People who self-harm hurt themselves as a reaction to the damage and gain relief or control. “well you know you’re ok. In contrast. which drives me nuts . emptiness. rage. whereas those who attempt suicide seek to put an end to a feeling of unbearable pain. the purpose of their behaviour is to die (152). . so it’s really hard to get what I want if I haven’t self harmed. cos [because] I’m stuck in this limbo”(P5). 32) (151). The next participant thought this was the only way she would get any attention but to no avail: When I haven’t self-harmed but feel in a dangerous spot that’s really difficult because they’re [health professionals] saying. anxiety. Being disappointed with learning to survive and needing to react to the damage led many participants to ambivalence about living. arrogance. I want to relieve emotional pain and keep on living. 154). uncertainty. intense and unstable: they cannot self-comfort (150).Struggling Striving Surviving 67 However.
Participants described having suicidal thoughts and feeling fearful to the danger they represented: I don’t get suicidal thoughts unless I’m really ill and when they come. I just felt I couldn’t continue” (P6). repeated overdoses.5 Ambivalence about living The second aspect of learning to survive was called ambivalence about living where participants questioned the purpose of surviving. Feeling unable to gain relief from being vulnerable due to the trauma of abuse led many of the participants to work up to suicide: “I was feeling pretty suicidal. so I wrapped sticky tape really . really scared [of what I’d end up doing]” (P7). I’m just trying to put things into place to fill up the gaps and then sometimes I think what’s the point it’s not really doing anything cos [because] I’m not feeling any different. (P2) When becoming vulnerable escalated and life became intolerable and untenable participants took extreme steps to ease their suffering: I’d put my hand through a glass window to try to slit my wrists with glass and that didn’t work.68 Dr Jenny Tohotoa 6. you know I’m an impulsive person. As the following participant explained: “I’ve had repeated tries. I think I was scared. repeated cuttings. many of the participants felt worn out and doubted they really wanted to continue the battle for survival. I was taking tablets out of the medicine cupboard without any idea of what they would do. just biding time. I’d stop answering the phone. As one participant described: “I was starting to shut down. Sometimes it’s all I can do” (P7). they may come fleetingly first. like I’ll have one or two during the week but then they start building up and then when it’s permanently in my head [and] that’s my constant thought all the time. wrist slashing and suffocation. I don’t know what for. the purpose of struggling on. battling the odds and overcoming being vulnerable. I often feel that I’m just biding time. then I’m in danger cos [because] I’m impulsive. opening mail. After so much distress and hardship. This same participant went on to say: I [still]] think ‘what’s the point’. (P7) Some participants had made multiple attempts on their lives and their suicidal gestures included overdosing.
not talking . Suicidal intent often led to hospitalisation for many participants: “I felt even worse and very. for me is another major thing” (P4). and was committed to [mental health facility]” (P6). Another participant talked about their need for control over their lives by always having a way out: “It’s always a choice to kill myself. or who is safe. 6. when they feel no power over life. A study of the management of suicidal behaviours by Fine and Sansone (1990) reiterated this concept when they found that some patients with BPD actually need to be suicidal. Learning to survive led most of the participants finally on a search for safety and greater protection to deal with living in a dangerous world. (P3) Kuritane (2008) in their study on rates of suicide in people with borderline personality disorder found 75% of their study participants had reported at least one previous suicide attempt (155) and Judd and McGlashan (2003) in their book on the development of BPD. talk of suicide becomes the patient’s primary mode of communicating distress” (p. It featured prominently in the participants’ lives. they retain the choice of death (156). This ranged from just being amongst strangers: “That’s actually my safe zone.204) (36). just sitting in the city. stated: “Like the baby’s cry. support and structure. makes me feel I’m very unsafe” (P2). All participants had experienced feeling unsafe as a child. With some participants the legacy they carried as a result of this was a blurring of boundaries with participants not being sure who or what was safe: “The stuff like not knowing the boundaries I suppose of what is safe.Struggling Striving Surviving 69 tightly around my neck and then put a plastic bag on and taped that and put another bag on and lay down on the floor. sometimes it’s the first choice” (P5). This blurring of boundaries or uncertainty made them feel unsafe: “put me in a place where I don’t know who’s there [or] what’s going to happen.6 Seeking safety The third aspect of learning to survive was conceptualised by the following participant as: “If I wasn’t feeling safe then I would do anything it took to get away” (P4). very suicidal and was found wandering the streets fairly badly cut up [and] waiting to die. The need for safety. With other participants having people around signified a sense of safety. which was highlighted in the basic social psychological problem of being vulnerable meant the search for more stability.
but having people walking around and I know that I’m safe” (P5) to getting married: “I got married very young. and the amount of compassion and understanding experienced by the participants. The positive response to hospitalisation was overwhelmingly related to staff attitudes. Likewise another participant who was involuntarily sent to a mental health facility explained that being there. looking for security and safety” (P4). was certainly safer for her than being at home: “I’d come to [mental health unit] for seven weeks and they did their best. within the hospital setting” (P4). As this participant shared: .70 Dr Jenny Tohotoa to anybody. Another participant shared that she went to hospital for safety and support: I do have certain coping things that I use and when they don’t work. and I know I should find another way of doing it but. I go in about 4 times a year. Seeking safety in hospital was identified as both a positive and negative experience for most of the participants. One participant who was a victim of incest reflected on the one time in her life when she felt safe: “I spent two years in the boarding school I went to [which I loved] it gave me a sense of normality and safety” (P6). but I would rather have been there than anywhere else” (P7). but they just didn’t know what was happening and I didn’t feel supported through it. Providing security in hospital was seen as lifesaving by one of the participants: “I latched onto a few of the staff [in hospital] and without them I wouldn’t be alive” (P6). 6. The two components of seeking safety became a) hospital care—positive and b) hospital care—negative. Some of the participants recognised their need for a safe environment: “Hospital had always offered me security and safety” (P6).6. I feel very safe there [in hospital]. so it’s been a combination of good and bad experiences.1 Hospital care—positive: contributing to seeking safety The first condition influencing seeking safety was the experience of a positive hospital admission. whilst not ideal. Participants’ attempts to seek relief from their self-harming behaviour or suicidal thoughts more often than not culminated in either a voluntary or an involuntary admission to hospital. I present to hospital not able to go on. just to get out of the environment that doesn’t feel safe (P7). “You know.
I needed some de-stressing and they did a lot to support me in that (P4).Struggling Striving Surviving 71 The last couple of years that I have felt suicidal and actually turned up at emergency. either in two minds or saying ‘if I’m left on my own I’m going to do this’ you know. didn’t treat me like a leper or like someone who’s just [you know] wanting attention (P6). when she first presented to hospital with an overdose: With the first admission I had this situation where they were really concerned about who I was as a person and the fact that I really was not well and that I needed some respite. and their response was excellent.2 Hospital care—negative: contributing to increased vulnerability (a) Feeling punished: One participant recalled an incident where the staff used overkill in their effort to contain her behaviour and left her feeling abused and punished. The positive experience of being cared for and acknowledged and validated led participants to feel a sense of safety and therefore less vulnerable and enabled them to look for ways to increase their autonomy and enhance their self-esteem. like you always get to talk to someone. They stayed with me.6. I needed some break away from life. Another study found that clinicians who understand the complexity and purpose of the self-harming behaviour are better able to provide clients with supportive and empathic care (157). 6. Supporting the previous participants experience was a study by Fallon (2003) who found that people with BPD valued their contact with psychiatric services (15). This increased the sense of being unsafe and being vulnerable: So [the attitude of staff ] shifted from [seeing me as] this patient who was obviously not well to being this psychotic woman who isn’t . Another participant praised the efforts of the staff who (she felt) were concerned about her as a person. it’s amazing” (P2). A similar experience and another way of providing a sense of security was described by the next participant: “The nurses come up to you. they come up and ask you if you want to see them during their shift.
This resulted in an increased sense of fear similar to a posttraumatic stress reaction. it wasn’t a safe environment for me to be in. This inability to feel safe added to the participant’s sense of vulnerability and failed to give them autonomy. If you have a few of them on the ward (people with BPD) it’s a nightmare.72 Dr Jenny Tohotoa capable of controlling her emotions and pathologising my anger and frustration to the illness and keeping me sedated for. . it wasn’t secure and the nurses weren’t specially trained (P7). it was quite scary” (P6). I’ve had some really horrific experiences with regard to physical illnesses. Similarly. We get down to the hospital and I’m shit scared of hospitals. one of the nurses from a mental health unit in the southern region shared the previous participant’s point of insufficient training in the management of borderline patients: I find this type of patient the hardest to look after. Another participant related: “I spent my 16th birthday in [mental health facility]. they all compete for the attention and end up splitting the staff because we have no way to deal with them (P10). other participants explained their fear of hospitals in relation to the experiences of previous admissions: “I have a major problem with hospitals. (b) Fear: Several of the participants described the heightened sense of fear they felt being hospitalised. I don’t think I’ve got enough training or skills to cope with the huge neediness and the attention seeking behaviour. and I refuse to stay in hospital and because they were threatening to lock me in a hospital I was threatening to kill myself and because I was threatening to kill myself they were going to lock me in the hospital (P3). so it almost sets up a posttraumatic stress type of reaction” (P4). but that was quite an unsatisfactory sort of place for me. I think it was for another week (P4). (d) Involuntary admission: Another participant described an incident involving the police and being involuntarily detained for her own safety and the no win situation that followed: They [the police] wouldn’t tell me what they were doing or why they were doing it. From a staff perspective of caring for the person with BPD. (c) Untrained staff: Not feeling safe with a lack of mental health trained staff was a problem for the same participant at another admission: I spent time at [general hospital] that same year.
For example. the tenuousness of their position was highlighted by the following participant. Participants employed self-harming behaviours and suicidal ideation and gestures in an effort to survive or give up the fight. As a result of learning to survive participants’ problems mounted up and their vulnerability increased whilst their struggle for autonomy decreased.7 Summary Stage one of the basic social psychological process of striving for autonomy was called learning to survive. . but “It’s an unbalanced way of looking at life and how to cope with it” (P4). They realised that they could not continue with their previous behaviours and responses and they became engaged in stage two of the basic social psychological process of striving for autonomy entitled finding answers. The stage consisted of three aspects: reacting to the damage where participants initially attempted to find some measure of relief from their dangerous world. Paris (2005) postulated that hospitalization is of unproven value in providing safety for [BPD] patients by preventing suicide (158).Struggling Striving Surviving 73 The benefit of participants seeking safety in hospitals was not recognised by other authors. I don’t even know that I’ll ever be there” (P6). Whilst the majority of participants remained more positive than negative in their pursuit of surviving. “I’m not there yet. 6. As this participant expressed: “It’s all related to what I learnt as a child and how I learnt to cope and survive in the circumstances I was in” (P4). Frustration and despair led some participants to the second aspect called ambivalence with living. This included using adaptive coping mechanisms and frequently using drugs and alcohol with little change in their vulnerability. for the majority of participants the need for safety and finding answers jettisoned them into a crisis. The third aspect of learning to survive was seeking safety and saw many participants requiring hospital admissions to ensure their safety as they became ambivalent about continuing the journey of living and trying to survive.
When entering the second stage of the basic social psychological process of striving for autonomy participants began to move forward and reclaim a better understanding of themselves and their lives.1 STAGE TWO: FINDING ANSWERS The second stage of the basic social psychological process of striving for autonomy was called finding answers. participants began to acknowledge the difficulties they experienced trying to find relief from distress of living in a dangerous world. During this stage. Finding answers set the foundation that enabled participants to take practical steps to move forward in their quest of striving for autonomy. As one participant explained: “It’s been many. The next participant discussed the positive change in lifestyle that she experienced 74 . The turning point made participants reframe and reflect on their life experience to date and encouraged them to make further changes in their lives in order to resolve living in a dangerous world.Chapter Seven 7. It provided them with information and a greater understanding of themselves and assisted participants in their movement towards striving for autonomy. the diagnosis of BPD was the turning point for them. without of course knowing that the way that I was surviving in my life was a result of this borderline [personality] stuff ”(P4). many years of all sorts of things going wrong. Entry to this stage occurred when participants experienced a significant event that they described as a turning point. The participants also experienced an opportunity to find an explanation for their lives so far. Having a definitive diagnosis of BPD encouraged many of the participants to research the meaning of BPD and subsequently find the impetus to increase their responsibility for themselves and their behaviour and endeavour to maintain some sense of equilibrium rather than chaos. For many participants.
Learning a new way to cope and maintain her life meant that hospital became less important and staying out of hospital more important: “I’ve built up a life that I’m happier in and feel safer. knowing that I’m not just weird or tripped out. In the context of this study.. The Macquarie Dictionary (Delbridge et al. the security. 7.1 Positive response to diagnosis Diagnosis of BPD provided relief and inspired participants to seek more information about their disorder to better cope and in turn move on from merely surviving.Struggling Striving Surviving 75 with an increase of self-support and commitment to autonomy. which became her turning point: I decided to get therapy. she finally made the decision to stop being a victim. but it wasn’t until I made a decision that I wasn’t going to be a victim anymore. 7. a crisis” (p. 1997) defined a turning point as “a point at which decisive changes take place.2 Turning Point The first aspect of finding answers was called the turning point. I decided to go into deep psychotherapy which helped me learn a lot and explained to a certain extent my behaviour. instead of just being treated for the impulses and reactions I was doing. a critical point. these definitions were relevant and an experience described by all participants. no. The two aspects of finding answers became a) turning point and b) gaining insight. that I could take charge of my life. (P6) Participants described their relief at being given a name for the feelings and behaviours that had made up their lives to date: “It’s such a relief for me knowing there is a name for my disease. For her. more content in than I did in hospital” (P6). after many years of self-harming behaviours and repeated hospital admissions with a diagnosis of BPD. not safer. 2279) (159). support and safety afforded in hospital had been the preferred option for many years. That was my turning point.2. rather than me worrying that I’m schizophrenic. As one participant explained. being borderline is better” (P3). Being able to make some sense of their lives was really important: .
that makes it really easy for me to explain to other people” (P3). For those participants with a positive outlook. wow. So that was big for me.76 Dr Jenny Tohotoa “Finding out about it [BPD] was really. but there was a genuine reason as to why my life was like that. really helpful cos [because] I’ve always hated myself because I never felt I belonged anywhere and now I don’t feel such a freak. it’s been an illness that’s created me dealing with stuff [in a way] that’s not quite societally appropriate. having a diagnosis gave them confidence and allowed them to own their feelings and experiences: “Being self-aware is important. Moreover “Once I found out that I had BPD and that I don’t have different personalities. It’s not been the world around me that’s actually caused this but it’s not been me either. like I belong” (P6). It was actually recognising that there was a genuine. cos [because] if you don’t know who you are. It was obviously the point in time where I decided that my mental . So that was really beneficial (P4). ‘how dare they put this label on me’. but for me it was quite an incredible experience. I finally have an explanation why my life is so screwed up. I’m not an alien anymore. As this participant stated: I’ve heard other people say. Knowing the reason for a lifetime of misery and alienation was very positive for some of the participants. I mean many people would disagree. and not using it as an excuse. that’s great” (P3). knowing that it wasn’t just [me being] crazy. how can you tell anyone else who you are” (P3). The turning point facilitated a change in how some participants managed their lives with a BPD as this participant explained: It took me a long time to learn that just because you stopped drugs it wasn’t going to be the end of the world. The majority of participants in this study experienced a turning point when they were confronted with a diagnosis of BPD following a crisis hospital admission. Most of the participants had engaged in some form of self-harming behaviour or suicidal gesture and subsequently come to the attention of the mental health care system where a diagnosis of BPD surfaced: “Knowing what my illness was.
She went on to say: “I’ve heard a lot of psychiatrists say ‘Oh no. I’m a burden. This was further reinforced in a study on the effects of the label BPD on nurses perceptions by Markham & Trower (2003) who found that staff had no sympathy and were pessimistic about the future of people with BPD and rated their experiences as more negative than working with patients with a diagnosis of depression or schizophrenia (161). 7. The thought of a lifetime of prejudice and discrimination led her to think about suicide: When I was admitted. Being given a diagnosis of BPD made some participants more aware of their inability to cope but they coped nevertheless by surviving. Similarly. 160). Participants expressed a conflicting range of feelings when confronted with the diagnosis of BPD: “It was a shock” (P7). the psychiatrist started reading out my list of labels.2. The attitude held by mental health professionals was also identified by other researchers (15. I’m a problem. and I’m the dregs of society” (P2). Shock and outrage were the feelings expressed by the following participant when given a diagnosis of BPD. Nehls (1999) likened the diagnosis of BPD to a death sentence for the person (25). I felt like I just wanted to walk out into the traffic there and then because I thought ‘do I have to face this for the rest of my life with people and what they think?’(P2).Struggling Striving Surviving 77 health was more important than the drugs. I won’t take on anyone with BPD [borderline personality disorder] cos [because] they just exhaust you and burn people out too much and I’m not going to risk myself ” (P6). I guess that would have been one of the main turning points (P3). and [he] mentioned at the end of the list of other labels [that] I had borderline personality.2 Negative response to diagnosis The basic social psychological problem of being vulnerable was increased with self-blaming and stopped the participant from the basic social psychological process of striving for autonomy. Another participant saw herself as a pariah with the diagnosis of BPD: “I looked at the term BPD and I hated it because a lot of patients and a lot of staff hate it and it scares them off ” (P6). “I freaked” (P4). The same participant went on to say: “I feel like I’m a real jerk. Steinmetz and Tabenkin . I almost felt like a jam jar.
So yeah.78 Dr Jenny Tohotoa (2001) found that health professionals reacted to patients with BPD with negative emotions. there’s something wrong with me now. which left her feeling more traumatised: If they suspect that you’ve got that kind of personality [BPD].2. Jim McGinty.1 Injustice The following participant illustrated an experience that highlighted the dismay. They get put in prison and have all this treatment and all that crap and everyone’s racing around trying to patch up their lives while we’re just given this very derogatory term (P2). beautiful. don’t tell anyone what you’ve been diagnosed with yet again. because they’re going to lock you up. Feeling discriminated by the system that treats the offender and leaves the victim uncared for. injustice and resignation she felt at the perceived lack of care and the intolerance of the health professionals. it’s a bit scary I suppose to actually go out there and admit in public. led this participant to share: I thought ‘Oh my god. okay. So of course it’s a case of bury your head under the sand. guilt and hatred (162). it’s all my fault” (P4).2. such as anger. . that this is the diagnosis you’ve got (P4). 7. (2005) who said: “Anybody diagnosed with a personality disorder we will lock up so they can’t commit a crime” [this was in relation to Mr Narkle]. it’s all me. The same participant explained her fear and shame of having a personality disorder was related to a press statement from the State Minister for Health.(P2). why do I have to have the derogatory label when all these bastards are walking free and even getting treatment for themselves. then they’ve got to look at it and deal with it straight away and do something pro active and help you instead of having years of trauma from it and being re-traumatised and re-traumatised. A negative outcome of the diagnosis of BPD was self blame as the following participant explained: “Personality disorder.
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This theme of injustice was reinforced by another participant who said: “Why do I have to suffer, I’m the victim here, where’s my life, it’s in the toilet. None of it’s my fault, it’s not fair” (P8). The feelings of guilt and shame increased participants’ level of vulnerability and made their quest for autonomy much harder to achieve. For all of the participants under study, whether they had a positive or negative response to their diagnosis, learning more about their diagnosis was essential to their journey for autonomy. To enable them to proceed, more insight was needed.
7.3 Finding a sense of self
The second aspect of finding answers was called finding a sense of self and during this aspect of the basic social psychological process of striving for autonomy participants began to make more informed choices about their lives and were more able to seek appropriate help. Finding a sense of self saw the participants gain an understanding of how to deal with living in a dangerous world by striving for autonomy. Participants talked about their wishes and thoughts on how to become less vulnerable and sometimes support from themselves was the first step towards a sense of autonomy as this participant explained. “Acceptance is probably the first bit and I think once I have accepted it [abusive childhood] then forgiveness will come, yeah” (P4). Affirmation from others made it easier to strive for autonomy to overcome being vulnerable by increasing the likelihood of finding a sense of self. 7.3.1 Therapeutic intervention Feeling creative and internalising that creativity helped this participant reclaim her identity: “It’s through my creativity, my artistic talents, that I’m me” (P2). Another participant explained: “It’s meant a whole lot of personal growth for me, acknowledging myself was a big thing for me to do. I’ve developed a belief in myself and I do what feels right for me” (P4). Psychological intervention over several weeks, whilst allowing the following participant to work through her relationship difficulties, was unable to maintain her and the need for psychiatric assistance was then explored:
I was seeing a psychologist twice a week and I got to the point after about 8 weeks I couldn’t learn anything more from her.
Dr Jenny Tohotoa
We’d been through all the visualisations, starting off as a seed and growing into a rosebush and of course I had ex boyfriends coming in and cutting off the rosebuds and they’d get frost bite and it got to a point where I couldn’t feel she was helping me anymore and that’s when mum and dad took me to a psychiatrist (P3).
7.3.2 Increased self worth Another participant shared their increased sense of self worth: “know who I am and I’m starting to accept that I am who I am, but, my core beliefs aren’t working so I need to deal with stuff that isn’t working and change a few of those” (P5). Another facet of gaining a new perspective enabled a participant to identify a new reality and recognise the place of drug use in her life:
It wasn’t until eight months ago that I stopped taking the drugs. I realized that those people [drug friends] were not my friends and the reason why they expected things from me that I didn’t feel were acceptable was because they were just all about the drugs. At the end of the line you have to take responsibility cos [because] you’re the one that’s decided that you were going to stop and [when] enough is enough (P3).
Gaining insight into how borderline personality develops from being damaged gave the following participant a greater understanding of what she was going through and allowed her to experience some self-acceptance:
This is what has happened in my childhood (being damaged happened), this is what it is all about. I still struggle; it’s an evolving journey for me. I have much more of an awareness now I suppose and yeah, acceptance (P4).
Similarly, another participant acknowledged the awareness of a shift in her ability to express her emotions leading to a greater understanding and acceptance of herself:
For me it’s like I keep everything inside. When I was first diagnosed, trying to talk about anything, get anything out of
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me was just about impossible. I’ve realized there were varying degrees of ok.[being alright] Now I sort of, I can come out and say more about how I’m feeling and I think that’s important because I could never understand the emotions, I could never get them out into the open. I was emotionally closed (P7).
7.3.3 Self protection Deciding not to engage in relationships the following participant highlighted her fears of sabotage by others on the path towards independence: “I don’t want any, [relationships] you know; I’m scared of relationships where people can interfere with that, [stability and independence] I don’t want to put that at risk” (P6). Learning to deal with problems and not escaping the emotional roller coaster of having BPD was also highlighted by the next participant who compared learning how to balance the emotional chaos of BPD to a juggling act: Staying with the fear and allowing the feelings to be, without being consumed or overwhelmed by them:
It’s quite challenging to do these things like stay calm and get through it, and it’s sometimes really hard to get through the day and juggle this mood stuff. I know what that is, it’s my illness going to me ‘fight, flight’ and grasping that and stopping with that and just staying and [you know ]doing whatever I have to do to process it and get through it. It’s not running away (P4).
Insight into the loss of self as a reaction to being damaged was also welcomed by the next participant, as it enabled her to have a greater clarity about herself: I could finally work out what was going on in my head” (.P3). Learning more of the ‘self ’ and the acknowledgement of the balancing act that constitutes adult life was eloquently described by the same participant:
There’s this little child side of me and I absolutely love the little child side but I now also have an adult side, and now that I know about my illness, it’s easier for me to differentiate between the two of them and know when I can allow the young part of me to come through and when I need to rely more on the more mature side of me.(P3).
Dr Jenny Tohotoa
7.3.4. Informal support The support and friendship from other people with borderline personality disorder enhanced striving for autonomy to overcome being vulnerable and was greatly appreciated “Having contact with other people with borderline has been really vital to me, because it makes me feel not so alone. It means that I can bounce something off somebody who understands, it’s the whole peer support stuff ” (P4). 7.3.5. Role of employment Employment and the availability of support and financial gain played a very small part in the lives of the participants under study. The burden of responsibility and commitment seemed to override the perceived benefits. As the next participant explained: “I can work, but I feel like I’m getting less satisfaction and I can’t be bothered” (P5). Another participant explained that whilst employment was certainly a plan, it was something that needed to be introduced very slowly: “I’ll definitely go back to work and yeah, it’ll just have to be starting out like real part time, and then just slowly, slowly working my hours up to something I can handle” (P3). Other participants were not able to work. As one participant stated: “I had tried at least 3 times to retrain and worked for a couple of years and it was just too much” (P6). Another participant was ambivalent about employment, on the one hand feeling disappointed in herself for being unemployed, but on the other hand, scared of employment: “I feel frustrated at my inability to get a job but I’m scared of a job, I don’t think I’m ready just yet” (P1).
7.4 Family influence: positive
Family interest in understanding borderline personality disorder allowed the next participant to feel cared for: “My Dad reads up a lot about BPD. He is just very interested in learning about these things, and he treats me like he cares” (P9). Another of the participants described how her mum had taken the time and effort to learn how to deal with BPD: “My mum’s read all the books about me. There’s a really good one called ‘Stop walking on eggshells’ apparently really, really good, tells you how to live with a borderliner [person with BPD]” (P3). In contrast to the previous participants experience a study of family members knowledge of
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BPD by Hoffman, Fruzzetti and Buteau, (2007) found, the greater the knowledge about BPD the higher the levels of family burden, distress, depression and greater hostility towards the person with BPD (163). Family support was identified by the majority of participants as very important in maintaining their connection to others and validating their experiences. One participant shared how her husband showed understanding which helped her to strive for autonomy to overcome being vulnerable. It afforded her a level of connection and support:
My husband’s a long way away [works overseas] and we talk a lot, and we don’t need to talk about in-depth things but there’s a connection still. We’ve been married for 30 years, and while I don’t really share my problems, he knows about the self-harming. I might say ‘Oh I’m feeling off ’ and he knows I’m not OK (P7).
More understanding, this time through acknowledgement and validation for being damaged helped with striving for autonomy to overcome being vulnerable. A lifetime of abuse was reinforced for the next participant by her sister who had also experienced the horrors of childhood abuse. She shared; “We’ve never talked about it before but we used to have these flashbacks and things but you know the one beauty of it is we know it’s true because we were there together” (P2). The importance of being accepted and forgiven for previous actions and the subsequent sense of support were highlighted by the following participant who expressed her gratitude for her children’s forgiveness, despite the trauma she had created in their lives: The interesting thing about it is the kids have forgiven me, which is quite amazing and really quite incredible and really rewarding. I mean despite my reactions to all kind of emotions and the way I’ve kind of dealt with stuff, my kids have actually managed somehow or another to see past that (P4).
7.5 Family influence: negative
Creating a sense of isolation, family members were not always able to give the necessary level of support or understanding needed by the participants: “my elder daughters they’re quite good about it [being hospitalized], but my son he never talks about it. My girls have been more
Dr Jenny Tohotoa
involved but we still don’t really talk about it” (P7). Expressing her sense of loneliness and isolation the following participant shared:
I never burden my friends with it [sexual abuse] ever; I just won’t turn to them at all ever. I’ve got my sister here, but then we find it a burden with one another with our stress cos [because] we both lost everything (P2).
Loneliness in the hospital for the next participant was heightened by the lack of contact from her family: “I think she [her mother] only came in half a dozen times to see me in those years “(P6). Another participant expressed her disappointment with the lack of family support, she said, “I slogged myself to death, you know I had two jobs so I could put them [children] through private school. They’ve both got good jobs, but do I hear any thankyous, no sir I don’t” (P2). She felt used and abused with no support or gratitude for her sacrifices: “they’ve used me and now they just dump on me. I don’t even see my grand kids, it’s not right” (P2). Feeling ashamed due to being judged and stigmatised many participants found their journey of striving for autonomy to overcome being vulnerable very difficult: “I think everyone is looking at me, I think everyone is judging me whether they be strangers, family or friends” (P9). Whilst many of the participants gained some insight into how to resolve living in a dangerous world one participant recognised that: “There are still some very narrow minded people and [you ] just can’t open their eyes because they don’t have empathy or a conscience or anything like that, they can’t understand” (P3). The quest for knowledge about BPD and the increased understanding of the effects of being damaged enabled most of the participants to continue with their basic social psychological process of striving for autonomy.
Coupled with an increased knowledge of their disorder they began to take more control over their life: “Now I know that the way I was surviving in my life was a result of this borderline stuff ” (P4). 85 . Knowing more about the meaning of BPD allowed some of the participants a freedom to pursue a different path and the need to understand their lives were highlighted by the participants’ search for answers through both reading and research into BPD. As the following participant explained: “I’ve now been clean [off drugs] for nine months. She went on to say: I still go out clubbing on the weekend but I just don’t put a $150 worth of drugs up my arm before I go out. The participants began to evaluate what had happened to them previously and to put that experience into some kind of perspective for themselves: the initial reaction to being damaged. As the following participant explained: “I’ve always enjoyed study to a certain extent. When engaged in this final stage of the basic social psychological process of striving for autonomy participants consolidated their movement towards autonomy by planning positive changes. I’m not trying to kill myself every time I come down (P3). one habit at a time. And I’m higher than I was on any drugs because I’m not on any drugs! I’m just happy to be alive.Chapter Eight 8. I still smoke marijuana but my psychiatrist says it’s ok.1 STAGE THREE: TAKING MORE CONTROL The third and final stage of the basic social psychological process of striving for autonomy was called taking more control. the ambivalence about living. cos [because] if I try and quit all of my habits at once something’s gonna [going to] give” (P3). the loss of self and the precarious security situation. baby steps.
8. so what do I need to do now? Much more of an awareness now—I suppose and yeah. I can’t change that [my childhood] that was life. The following participant described this shift in control through a dream. When participants gained insight into the disorder of borderline personality and began to understand themselves better. like all my dreams. once I started getting treated.2 Moving forward The first aspect of taking more control was called moving forward and looked at the ways participants continued to survive and manage their lives with a BPD: “I’ve done it all myself. I was in control (P3). that was what happened and this is me now. You should have seen how bad I was” (P2).86 Dr Jenny Tohotoa I’ve found the more I’ve read about mental health the more fascinating it is” (P6). . She went on to relate how she had suffered with terrifying nightmares for most of her life. acceptance (P4). I’ve stopped doing the ‘if only’s’. as a result of what happened. they learned new ways to find safety and stability and they moved forward towards accepting more control over their lives. I was running away from people and I’d have a moped or a ski and I’d just jump over them and it was totally different. Taking more control for their lives and achieving personal growth gave the participants an increased sense of confidence: “I think I started to make some conscious decisions to get some control in my life” (P6). The third stage of the basic social psychological process of striving for autonomy called taking more control consisted of three aspects: a) moving forward b) practical measures and c) skills training. all my night dreams changed. Participants were now ready to utilise their newly found insight into living in a dangerous world and being damaged and vulnerable as this participant shared: It is about not blaming the world so much anymore. and explained the changes that occurred in her dreams following her therapy: I’d be in a dream and I’m trying to run away from something and I just don’t have the energy to move and I’m [like] grabbing onto things trying to make myself move and then.
(e) Not hiding the mental illness: “I don’t hide my mental illness from them. I think that was one of my major steps. It’s a conscious decision now. I’d started caring for myself and starting to accept my body a little bit. apologizing for all the harm I’d done to it. I was starting to get recognition and attention brought to myself for positive things that I was doing and I kind of liked that (P6). it was like giving the perpetrators control. (g) Taking conscious decisions: “I can still see the off ramp and I can see my road and I know the road is the best way but I still take the off ramp. (d) Establishing further safety: “Having lots of safety nets and safety people” (P1). by making lots of boundaries” (P1). I was able to stop myself from getting into a situation where I was going to react badly” (P3). I’m quite open and honest about it with them and if they want to know something I’ll tell them” (P4).Struggling Striving Surviving 87 8. and it’s meant a whole lot of letting go” (P4). instead of just falling into the off ramp” (P5).2. (i) Not self-harming any more: I couldn’t continue to do that [self-harm] to myself.1 Ways of taking control The participants described a range of “taking control” measures they employed in their efforts striving for autonomy. but after the last two times I didn’t bother to beat up on myself cos [because] you know it makes you worse” (P2). (b) Digging in my toes: “Digging my toes in and being really stubborn” (P4). So it was like my mind addressing my body and that was interesting (P6). . (c) Putting in boundaries: “That’s how I live now. (h) Treating the body better: I wrote a letter to myself. (j) Reducing self-hate: Another participant shared: “I used to beat up on myself when I went to hospital. (f ) Not going into a situation where they would react badly: “I knew how I’d react to things. (a) Letting go: “It’s meant a whole lot of personal growth for me. cos [because] up until then I rejected my body. hated my body. to my body.
3 Engaging in practical measures The second aspect of taking more control was entitled engaging in practical measures and identified the myriad of ways used by the participants to accept and implement some level of control over their lives. Getting back some level of control. (d) Planning ahead: Keeping occupied and making plans in advance played a large part in staying motivated for the next participant: “If I get bored and depressed I don’t have the motivation myself. because that helps” (P1). Participants engaged in a variety of practical measures to assist in their pursuit of autonomy and learning more about themselves enabled the participants under study to engage in striving for autonomy to overcome the problem of being vulnerable. (b) Exercise: Enrolling in an exercise program was something new for the next participant: “I’ve just started an exercise program” (P1). If you can’t laugh at yourself then you leave yourself wide open for people [to be] laughing at you” (P3).88 Dr Jenny Tohotoa (k) Doing the best one can: “To get that step closer to the acceptance of ‘doing the best you can’. 8. which has almost become my motto. helping them to better manage being vulnerable and move forward. (a) Having a sense of humour: One participant suggested learning to laugh at yourself was a valuable asset that also decreased her vulnerability: “Learn how to laugh at yourself. (c) Religion: Another participant related to the researcher the important part that religion played in her life: “my religion was very important to me” (P6). (e) Strong role models: Reading and watching on television how “Prime Suspect” Chief Inspector Jane Tennyson managed her life was inspirational for this participant. . just as long as you’re doing the best that you can” (P4). cos [because] if you laugh at yourself then no one else can laugh at you. enabling them to move forward in their lives. not only to pick up the phone but leave the house. Developing more adaptive coping mechanisms that included self-observation increased the participant’s chances of learning more about themselves. I like to make plans in advance.
and that gave me a sense of achievement from being creative” (P6). I wanted to be Chief Inspector Jane Tennyson. She went on to say: I read lots of crime. like digging out a garden bed and laying concrete paths that I could physically do and that’s what I think has helped me (P6). and in her search for stability: I started getting pleasure out of little things. I think cos [it’s because] I was targeted since I was a girl and it’s the paedophilia thing and now I’m an adult and they don’t really have the power anymore. (h) Gardening: Gardening played a large part in the next participant’s sense of control. (i) Stopping drug abuse: Reducing the confusion by giving up drugs and facing life without the chemical overlay gave both these participants more control in their lives. like the garden and the achievement of creating things. by reading these books and fantasizing that I have the power to do this to these people and therefore they can’t hurt me anymore. like the more gruesome it is the better.Struggling Striving Surviving 89 having a sense of power rather than feeling powerless was important for her. A talent for craft led the next participant to teach the craft increasing her self-esteem and sense of personal achievement: “I was very interested in crafts so I did a course and became a qualified teacher. I think that’s how I control or feel like I’m accomplishing something. So it’s lots of positives” (P1). I just wanted to be her. so I can expose them. Another decided that: “I don’t want to do . it’s weird. One participant “replaced [her] speed habit with shopping” (P3). if anything it’s more like I have the power over them. I feel better about myself (P1). (g) Everyday chores: Another participant found the simplicity of routine cleaning helped her feel more positive and accepted within the family: “I just kind of go round cleaning and fixing and that makes me feel better and it looks nicer and my parents really appreciate that. (f ) Creative pursuits: Many of the participants referred to their creative talents and leisure interests. Discovering a sense of self-identity and embracing the experience through creative pursuits gave several of the participants a newfound life.
90 Dr Jenny Tohotoa that. (a) Time for reflection and growth: One participant entered a personal support program [Centrelink] that ensured she had psychological support for the next twelve months: “I don’t have to look for work. One reason that I got him was to make me do more exercise and to have company. and I’m learning new things to help me” (P3). The therapeutic interventions ranged from government initiated support programs for the unemployed to the “Changes program”. Each of the participants was involved or had been involved with some form of skills training at the time of interview.4 Acquiring new skills The third aspect of taking more control was acquiring new skills and encompassed the different therapeutic interventions that the participants encountered. So I did that and that was good” (P1). I’m not trying to kill myself every time I come down and stuff like that” (P3). And the realization for the next participant that: “I’m just happy to. The following participant recognized the benefit of a mood management course in helping with anxiety and stress: “I’ve been doing a mood management course and that’s helped a lot. I also have to take responsibility for him” (P6). (b) Skills training: Being involved with a Dialectical Behaviour Therapy (DBT) group gave the following participant an opportunity to gain . Involved with that decision was the realization that life was less confusing straight: “I don’t have anything really bad in my body except pot and I’m feeling a lot better and a lot less confused” (P1). In addition. They taught me a calming technique which I used today because I was a bit anxious about you coming over. Another participant was enrolled in a Centrelink program: “I am with a Community Links Program it’s about like an 8-week intensive support program. another participant explained the importance of her dog in decreasing her loneliness and keeping her active. (j) Keeping pets: The addition of a pet in the household had a very positive effect on some participants’ lives: “the cats keep me sane” (P1). which encompasses life skills training with intensive psychological support for people with a personality disorder. I don’t want this chemical life anymore” (P1). 8. be alive. “Three years ago I got a dog and he’s basically helped me. and I don’t know after that” (P9).
(c) Psychological support: Being understood was really an important part of the therapy process for this participant as she explained: “The therapist was really helping me. She went on to relate how she was now able to deflect her family from causing her distress: I can make my life easier and it upsets me when I talk to my family about how I’m feeling. . Whilst understanding through therapy how an abusive childhood influenced her life. There’s a solidness. Another participant shared her understanding after therapy. the following participant remained unforgiving of the perpetrators. It was just like one day I’d be walking along and the next day I’d fall in a hole. I felt she understood me. “It’s all to do with my upbringing and I can recognise that now after having done the treatment programs that I’ve done” (P4). of the part her abusive childhood played in her life. Supportive therapy with a psychologist helped the following participant better understand the process of depression and to recognise and better manage the black hole in which she frequently found herself: I was emotionally closed. and I’ve got the choices to make the decisions and the skills to carry them out” (P6). I just didn’t know what happened for me. My therapist got me to slowly stand on the edge and know it’s a hole and now I can walk around it and sometimes I still fall into it but more often than not I can walk around it (P7). She related. “I’ll never forgive them [sexual offenders]. The skills help in everyday living and make my life easier” (P6). I had no idea how I got there and I had no idea how to get out.Struggling Striving Surviving 91 confidence and experience an easier lifestyle: “I’ve committed myself to the course [Dialectical Behaviour Therapy] and do it in detail. I avoid the situation where we talk about disturbing things (P6). I’m not a reaction. Having learnt to make choices and gain skills to enable her to make decisions and developing the confidence to maintain those decisions the same participant shared that: “I don’t have to accept their [other people’s] judgement. That was so great” (P6). so I don’t talk about it. Any time they keep persisting.
Helping other people was an important point in taking more control. For her. the security and safety afforded in hospital had been the preferred option for many years. I understand that you feel like that and that’s your feelings but don’t put that on me. thanks to my therapist. so I’ve trained my mind to leave my shit at the door and help other people. but I’m done with being the victim. Learning to be more assertive and accepting more control over her life was one of the new skills learnt with supportive therapy and she was able to acknowledge that other people had issues without taking responsibility for them: I really think that people have got their own issues to deal with and I’ve got enough of my own without having to be made to feel guilty for them as well. no not safer. “I’ve built up a life that I’m happier in and feel safer. but I had a review on Monday and they said. Participants explored their options of therapy. (d) Group help: Learning to accept rather than to give was a lesson learnt through the group process. I should be doing that. and was able to hear from the therapists that he was also entitled to receive input: Changes program is a support and I’ve been leaving my bags at the door and giving input to other people. the facilitators go yeah. (e) Community life: Another participant described the importance of feeling more safety and contentment in a life out of hospital. open your dirty laundry and shake it out’ and I’m going yes.(P7).92 Dr Jenny Tohotoa I’m making more sense of my life. Feeling guilty and responsible for everyone else had been the usual pattern of behaviour for the following participant. yes. ‘bring your bags in mate. developed routines to afford them more stability and structure in their lives and found creative pursuits that helped many of the participants with an . Learning a new way to cope and maintain her life meant that hospital became less important and staying out of hospital more important. that was really good. because the stuff I say. for the next participant. I’ll do that and I did that (P5). it’s not going to be me anymore” (P8). good thank you. He identified his need to always be there for others at his own expense. more content in than I did in hospital” (P6). I’ve got enough to deal with on my own’. Now I tend to say ‘look.
many of the participants engaged in a therapy program or sought individual therapy to increase their self-awareness and gain more control for themselves over their lives. when they experienced a turning point. Their vulnerability decreased proportional to their increased autonomy. all . Some participants used drugs and alcohol to avoid dealing with their alienation and when they realised that this did not meet their needs. called learning to survive occurred as a consequence of the basic social psychological problem of being vulnerable. entitled finding answers. During this phase. The first stage of the three-stage process. living in Western Australia. Perceived maladaptive behaviours of manipulation and acting out were the less destructive behaviours employed by the participants. their self-confidence increased and many of them were able to acknowledge for themselves the positive changes to their lives.5 SUMMARY Participants. 8. Gaining insight followed the turning point and enabled the participants to have a better understanding of their lives to date Participants then entered the third stage of the basic social psychological process of striving for autonomy called taking more control.Struggling Striving Surviving 93 increased sense of self-identity. As the participants accepted more control over their lives. they made self-harming or suicide attempts to get the attention they needed which often found them hospitalized for containment and greater safety. Experiencing a turning point made participants realise that there was an explanation for their behaviour and that it came at a price. The participants planned for positive changes and took practical steps in order to participate in life and belong and at the time of being interviewed for this study. By striving for autonomy. In this stage. participants were able to reclaim their lives and participate in life rather than just exist. shared a common basic social psychological process of striving for autonomy. who had a BPD. Participants engaged in the second stage of the process of striving for autonomy. participants struggled to manage the basic social psychological problem of being vulnerable and were involved in risk taking behaviours unable to control many aspects of their lives. A turning point often occurred following the diagnosis of BPD and was either a negative or a positive experience for the participants.
Searching for relief and safety brought them to the attention of mental health professionals and this influenced that experience. Their engagement in stage three was determined by their need to escape to safety from living in a dangerous world and their desire to change the self-harming behaviour that increased their vulnerability.94 Dr Jenny Tohotoa of the participants were engaged in the final stage of the basic social psychological process of striving for autonomy. .
attention deficit disorder. Prescott and Kendler (2005) co morbidity can be divided into two categories. low self-esteem and sometimes paranoia left many of the participants emotionally disabled. Those disorders/ illnesses that relate to mood and include major depression. posttraumatic stress disorder and bipolar type 2 that the participants had been labelled with over the years by health professionals. abandonment. 9. According to Jacobsen. and 3) level of support. Three conditions were identified as influencing participants’ movement towards their endeavour for autonomy and these were: 1) co morbidity—influence/impact of an existing mental illness. panic disorder and phobias. because most participants also had a secondary diagnosis that actively influenced their mental state this compounded their capacity to strive for autonomy to overcome being 95 . generalized anxiety disorder. However.Chapter Nine This chapter presents the conditions influencing the basic social psychological process of striving for autonomy to overcome the basic social psychological problem of being vulnerable for people diagnosed with a BPD.1 CO MORBIDITY-INFLUENCES/IMPACT OF AN EXISTING MENTAL ILLNESS The first condition identified to influence participant’s movement towards autonomy was called co morbidity—influences/impact of an existing mental illness. Participants in this study have demonstrated that having a BPD is difficult enough and being subjected to feelings of emptiness. Gardner. The term co-morbidity for the participants related to the accompanying documented psychiatric diagnoses of depression. 2) low threshold to stressors due to increased vulnerability. and those disorders/illnesses that relate to substances and behaviour (164).
9. They concluded that a lifetime pattern of complex psychiatric co-morbidity has strong predictive power for the diagnosis of BPD (165). hypomania and attention deficit disorder often increased the danger.1 Medication-negative effect Several participants in this study recalled years of non-treatment or under treatment of their other mental disorders and accompanying symptoms. Frankenburg. Making it more difficult to strive for autonomy to overcome being vulnerable. Similarly. Vujanovic. It makes me feel ticklish when I’m happy so I know I’ve got lots of serotonin running around my body cos [because] it feels ticklish. Reich & Silk (2004) showed an association between BPDs and psychiatric disorders such as major depression. As this participant explained: He [the psychiatrist] put me onto [an antipsychotic] which stops my mental outbursts but with being on antidepressants and an antipsychotic it made me have no mental coordination and I smashed my car into a tree in my own driveway and my head went through the windscreen (P3). The effects of the medication used with the participants to treat the symptoms of depression. I’m not crying over nothing as much. either (P1). the tablets don’t seem to work” (P2). She went on to say: “I tried six different medications and they all had different affects but none of them had the right effect” (P3).1. one in the morning and one at night and since I’ve been on them I’ve felt a lot better actually” (P7). and bipolar illness (165). Another participant expressed their belief that antidepressant therapy was helpful and aided their quest for more self-control and internal energy: I don’t really feel that down at the moment and I feel it’s the new medication [antidepressant] I’m taking. .1. Zanarini . One participant related: “I was diagnosed with major depression for a good four years before anyone actually did anything about it” (P3). leaving it more difficult to strive for autonomy to overcome being vulnerable. Hennen. 9.96 Dr Jenny Tohotoa vulnerable. led to further self-harming behaviour: “I start getting really depressed. then all these other thoughts of self-harm come in and that gets worse and worse.2 Medication-positive effect The next participant was able to identify an improvement in her mood following antidepressant therapy: “I’m on two different antidepressants.
the following participant experienced a wide range of emotions and mental states increasing her vulnerability: “I was diagnosed with chronic fatigue and bipolar 2 and that sure stuffed me around. Similarly. as the hypomania gave a false sense of coping and well being. I go into this really high state and I think that I’m fine. then I would go hypo manic with my bipolar.2 LOW THRESHHOLD TO STRESSORS DUE TO INCREASED VULNERABILITY The second condition affecting the basic social psychological process striving for autonomy to overcome the basic social psychological problem being vulnerable was called low threshold to stressors due to increased vulnerability. one of the participants described her struggle to understand her world as she fluctuated between depression and hypomania.Struggling Striving Surviving 97 Another participant explained that: “working with a therapist and taking antidepressants” (P8) had helped to put some control back into her life. up one minute. flattened the next: I couldn’t ever rely on myself. 9.1. cos [because] I wasn’t okay” (P4). What would be .3 Compounding symptoms Having another mental disorder made striving for autonomy to overcome being vulnerable more difficult: Having to deal with other mental health signs and symptoms prior to the diagnosis of BPD. although I didn’t know it was bipolar at the time. Really stupid thing to do. fluctuating mood swings generally made striving for autonomy to overcome being vulnerable more difficult to achieve because participants often delayed from seeking professional help. She explained: I had a really major depressive episode. maltreated or abused in childhood developed a heightened sensitivity to their environment which led to an increased sensitivity to stress. These frequent. Participants who had been neglected. but of course I’m not (P4). The difficulty for treatment was highlighted by the same participant when she discharged herself from the community clinic whilst experiencing periods of hypomania or overactivity: “I just told them I was much better and didn’t need to see anyone anymore. 9. and there was no-one else” (P8). Living in a dangerous world is highly stressful and striving for autonomy to overcome being vulnerable required superhuman effort and ingenuity.
it’s too much for my mind to [like] cope with and I just stress out” (P3). ignorance and judgement of BPD that impacted on the participant’s striving for autonomy to overcome being vulnerable. stress. “I don’t know. 9. I’m better if the decisions are made for me. I just lose it.1 Internal conflicts As a consequence of living in a dangerous world participants talked about the stress and anxiety they experienced even with everyday problems.2. (a) Having to wait: Simple things like having to wait was experienced as stressful: “I hate waiting. I just can’t wait. no doubt connected to living in a dangerous world. I’ve been going around . and the physical ramifications of that stress: “I suffer with very high anxiety I grind my teeth and everything. (e) Feeling trapped: The following participant talked about their life being like a never-ending circle. Many of the participants expressed the anxiety they felt with even low levels of stimulation and their high anticipation of harm. I know where I am then” (P8). The participants’ experiences reflected the hypersensitivity to stress and the difficulty that caused in their day to day living. that continued to impact on their inability to tolerate stress. people don’t understand. (d) Making decisions: “I can’t make decisions. The abusive. (b) Feeling crowded: Too many people in a room: “If there’s too many people in a room and there’s too much stuff going on. (c) Physical response: Stress had the effect on another of the participants who described their ongoing battle with anxiety. I just panic” (P1). Worries and concerns for themselves and others adversely affected many of them and they talked about increasing levels of internal conflict resulting in more stress and anxiety whilst interactions with health professionals and others raised the issues of intolerance. Participants described a wide range of situations that evoked strong stress and anxiety responses. I don’t know who to please. see my teeth are gradually grinding down” (P2). fearful experiences in childhood.98 Dr Jenny Tohotoa considered “normal” to most people became overwhelming for some participants. Fear and anxiety experienced in being vulnerable from living in a dangerous world were always present for the majority of the participants and this adversely influenced their response to perceived stressful and anxiety provoking situations.
(j) Fear of relapsing: Trying to maintain any sort of equanimity found the following participant reflecting on how easy it was to slip back into being vulnerable and highlighted the need for constant vigilance to maintain safety: It’s still an evolving journey for me. the boundaries. I feel nauseated inside and time seems longer. (g) Fear: The ongoing anxiety for most participants was directly related to the vulnerability experienced as a child in an abusive environment and the inherent fear that engendered. I just hate social situations. I go to parties with people or I see old family friends and it’s like ‘what do you do?’ and I’m like on the dole. the fact I don’t have any achievements under my belt (P1). I haven’t had a job since I left high school in Yr 11 and I haven’t finished uni [university]. (i) Time distortion: Another participant described the stress and anxiety she experienced attending social occasions. I suppose of what is safe. I heard he [sexual abuser] became a taxi driver. That makes me feel the worst about myself at the moment. even though she had learnt (through therapy sessions) to be happy in her own company and stay grounded. and there are certain times that I slip back into the old stuff. “It’s so stupid. coming back to itself. She described the sense of time elongating: “I’m happy with my own company now. (h) Feelings of failure: Internal conflict occurred in a variety of situations for the participants.”(P5) (f ) Feeling unsafe: Each of the participants had experienced feeling unsafe in their childhood and one of the legacies they carried was having blurred boundaries. The legacy of childhood abuse for the following participant incorporated a fear of taxi drivers that stopped her being able to access that particular mode of transport. As one participant described: “The stuff like not knowing. . One participant shared her sense of failure and disappointment at her lack of life achievements. does the circle break or does it just keep spinning and spinning and spinning. and the stress inherent for her in that situation: I hate it. Frustration kind of crops up or I have a lot of stress go on and its straight back into the old coping mechanisms and then it’s a case of having to kick myself up the arse and take the control back (P4).Struggling Striving Surviving 99 in circles for so long thinking well. so for years I was fucking scared of catching cabs” (P1). not being sure who or what was trustworthy and that added to their internal conflict. for me is another major thing” (P4). or who is safe. I hate it” (P2). but I still find it very hard.
ignorance. the following participant described the traumatic climate that her BPD had created for the children and the resulting loss of custody and need for psychiatric care that ensued. The participant’s hypersensitivity to ‘normal” situations increased their vulnerability and decreased their ability to be autonomous. my mother and my sister and me: we lose everything until we come down to nothing and even hardly yourself in the end” (P2). He struggled with the concept of part-time parenting and was not able to see a middle ground for shared care. I either move back in or I don’t see them. stigma . [because] there was no emotional regularity happening. but at the cost of potential close friendships and intimate relationships. cutting. all three of them. black or white. there were coke cans cut up and you know cutting the coke can around and using it like a slasher and they were like taking their bandages off to show us and it was like ‘Oh my God’. so they now live with their Dad full time. judgement.2. ‘Oh my God’. burning. there were so many young people. Continuing with the theme of loss. slashing. stress and conflict occurred for several of the participants in relation to the custody of their children. A similar situation involving the loss of custody for their children was described by the next participant. this is an epidemic (P2). My kids have ended up in psych care. these kids have always had a life that would have to be classified as traumatic (P4). 9. It got to the point where I couldn’t look after them anymore.100 Dr Jenny Tohotoa (k) Familial pattern: “It’s a family pattern. it’s still a core belief in my mind. External conflicts The second component of low threshold to stressors was entitled external conflicts and incorporated the intolerance. I couldn’t look after me let alone them. they were doing it while they were in there. The difficulty of the stress experienced by the participants was reflected in their behaviours and involved a great deal of distress and sense of failure.2. I’d rather their mother look after them like she’s been doing for the last 7 years” (P5). (l) Loss of children: Unable to adequately care for herself and subsequently her children. Everyone of them. He said: “With the kids. (m) Taking on others pain: While I was in hospital this time. Being hyper-vigilant did allow participants to continue to survive.
stigma and labelling. being invisible and not worthy of treatment which in turn affected their levels of vulnerability and impacted on their ability to survive. friends and health professionals to striving for autonomy to overcome being vulnerable such as the participant’s sense of not being acceptable. “Before 2000. Starr (2004) in her study of self-mutilation found that clients who self-mutilate perceive they receive poor care in hospital emergency departments and are re-traumatised by these experiences (157). had the most negative attitude.2. (a) Negative attitude from staff: Participants under study expressed their fear and distress at the negative attitudes from some staff when they presented for treatment. The two aspects of external conflicts became a) intolerance and ignorance from others and b) judgement. The attitude of health professionals that makes striving for autonomy to overcome being vulnerable so much harder is reflected in the comments from a nurse working in a secure unit in the Perth metropolitan area: You have a mixture of psychosis and depression and then you have the PDs [personality disorders].Struggling Striving Surviving 101 and discrimination experienced by the participants from themselves. Interestingly. saw less need for further training and had less optimism for change (166). You have care plans for the first two.1 Intolerance and ignorance from others The first aspect of external conflicts was called intolerance and ignorance from others and incorporated the contributions in different ways from family. The staff’s ignorance of BPD and how to effectively respond to these patients supports this attitude of ignorance and ineffective management. 9. Health professionals being angry increased the difficulty in striving for autonomy to overcome being vulnerable.2. I would say I was received [on presentation to the emergency department] extremely negatively with a lot of anger [from health professionals] (P6) which “led to more feelings of rejection and more feelings of self-hate and guilt and shame” (P6). male staff and medical staff in particular. A study by Mackay and Barrowclough (2005) on the attitudes of accident and emergency staff to deliberate self-harming behaviour. Similarly. their families and friends and from their interactions with health professionals. but with the PDs and the borderlines . found evidence to support the current participants account.
Deans & Melocevic (2006) found in their study of nurses response to BPD. I don’t think anything can happen now. most of the time we have to “special” [put a one on one] them and that really sets the others off (P11). but nobody has ever dealt with that in the mental health system. (b) Inappropriately medicated: If participants grieved at the losses they had experienced. a study by Deans and Miocevic (2006) found a proportion of nurses experience a negative emotional response and attitude towards people with BPD and regarded them as manipulative (167). it was seen as pathology that needed to be treated with medications: I’m too scared of my children and I don’t see my grandchildren so it’s pretty painful. you can’t generalize. cos [because] I don’t trust them [health professionals]. They’re so demanding and they cause so much trouble between the staff. You don’t get enough training to know how to handle them properly. The same participant again voiced her disappointment and frustration at the health professionals who had failed her and failed to accept and treat striving for autonomy to overcome being vulnerable: . they make it so difficult. (c) Lack of empathy: Lack of empathy and understanding by health professionals compounded the suffering of the participants and led to a lack of trust: “I truly think I’ve been so traumatised by the system.102 Dr Jenny Tohotoa in particular. I think I’m left with the legacy of the system. I literally don’t trust them” (P2). we have to medicate it (P2). It’s like if I cry over it or start to get upset over it it’s like ‘how much medication are you on? It’s like let’s stop these women and these people from grieving. like it’s not normal to grieve. Likewise. Instead of being given support workers to help cope in their environment the same participant said they were just offered medication: I’ve never been given or offered a community support worker or a housing support worker or any help with my kids or any help with nothing basically and maybe that’s why all they did was [like] shove pills down my throat (P2). that nursing staff were not empathetic towards patients with a diagnosis of BPD (167). Supporting the experience of this participant.
The reality of an imperfect health care system was highlighted by the next participant who talked about the concept . (e) Family shame: Ignorance and intolerance was not only confined to the health care system. “At times the self harming behaviours have driven people away and it’s not me so much that repels them. the cuts are nothing” (P7). instead of making you beg almost for care” (P2).Struggling Striving Surviving 103 They [health professionals] say ‘Oh you need to put it all behind you’ and I say to them “history shapes the future” and that’s what you have to look at. which I understand but. That’s all. it’s humane. which produced shame and distress in participants. One participant related her distress with the negative attitude and judgement from her family when she needed to go to hospital for safety. they don’t understand that to me that’s nothing. (d) Lack of understanding: Ignorance by health professionals in regard to the underlying meaning and relevance of self-harming behaviour was witnessed by many of the participants. it’s the behaviour” (P7). (f ) Being judged: The intolerance and ignorance of BPD experienced by participants sustained their vulnerability and made if more difficult to achieve autonomy. Health professionals’ intolerance and ignorance about striving for autonomy to overcome being vulnerable was identified by the following participant: “They [medical and nursing staff ] could have done it [medical records] in one page and said ‘this person has been severely traumatised and needs kindness and care’. She went on to say. She also shared her experience of prejudice and judgement from her family and the lack of support and understanding for her courageous journey: “When somebody says to you ‘I don’t allow myself the indulgence of being depressed’ then you know they’re just not going to understand” (P6). As this participant reported: “They just see the physical trauma like the cuts or whatever and they’re horrified by it. You have to realise where I came from and the way my parents parented me and the way I’ve parented my children and then you’re telling us all about this intergenerational stuff and you’re not doing anything to help (P2). Family members contributed to striving for autonomy to overcome being vulnerable. it is so simple. She related: “One of the worst things about going to hospital was notifying my family and confessing that I’ve failed again. Ignorance of the process of striving for autonomy is seen as failure instead of trying to survive (which is a positive thing). and it not being seen as a step towards keeping me alive” (P6).
2 Stigma Striving for autonomy to overcome being vulnerable was also increased because of overt prejudice and stigma towards participants. They didn’t ask. He said ‘look at all these other cuts. you feel like the dregs of the earth.2. but found that not to be the case for herself: “To hear somebody whom society has taught us is meant to be a caring professional. they [the nurses] couldn’t understand why it wasn’t safe for me to have those things closed. it’s pretty scary” (P4). really. Stigma is about disrespect. really big. (g) Feeling unsafe: Not able to express fear nor explain their vulnerability left some participants feeling very unsafe whilst in hospital. as if to say ‘this is the same old stuff over and over again’ (P6).2. meeting us with a judgement of ‘how dare you do that to yourself ’. As a consequence: “it increased the whole futility of the life I was living” (P6). the doctor came around with all these other people [student doctors] and made an example of me. 9. (h) Feeling exposed: Health professionals being judgemental increased striving for autonomy to overcome being vulnerable more difficult because they used participants as exhibits and blamed them: When I turned up in emergency with [self-inflicted] cuts.104 Dr Jenny Tohotoa of nursing and medical staff being caring. these other scars’. You know you can’t be honest with them [health professionals] cos[because] if you’re honest then you’re going to be judged and if you’re judged then you’re going to be judged not worthwhile (P4). they were so judgemental” (P4). Health professionals being judgemental increased this participants fear and feelings of being unacceptable if she was honest with them: The honesty thing for me has been huge. Stigma is not just the use of the wrong word or action. Health professionals being judgemental increased striving for autonomy to overcome being vulnerable because: [They make you feel as if ] you’re totally subservient. As this participant described: “Little things like having to have a door or a window open. It is the use of negative labels to identify a person living with mental illness . occurring in different locations and with different audiences. You don’t feel you’ve got a right to anything and you feel so bad you haven’t even got the empowerment to ask questions (P2).
They just give me loads and loads of pills. like maybe you were something less than others” (P7). just look at their language. a former Commissioner of the New York State Office of Mental Health who said: “Apparently the greatest sin a client can commit is poor response to treatment. How health professionals stigmatise people with BPD is illustrated in the following example by Dr Joel Dvoskin (1997). it was a bit of a stigma. High dependency. treatment resistant and bloody hell if you took your car into a garage and the mechanic came back and said. it’s a bit different from being told you have depression. Well. stigma by being diagnosed and thus labelled led to health professionals perceiving them as not deserving of treatment and them not receiving . According to participants. either they’re not looking at the problem properly or they’re not looking in the right places or they’re not using the right bloody tools to fix it. But I’ve been in therapy for 4 years so sometimes I question how useful it really is (P3). You tend to get stigma from the psychiatrists if you have that diagnosis. just by the very language they [health professionals] use. Well. that’s the same for people (P2). One participant related an experience which made it more difficult striving for autonomy to overcome being vulnerable: It’s very difficult to live with. They don’t make us feel very good and we have simply given up on helping people who desperately need us to do a better job helping them” (p. 1) (169). Another participant highlighted what stigma means in a comparison of BPD to a used car and the perceived lack of understanding about how to give care to the person with BPD: They [health professionals] talk about the stigma coming from the outside. you’re car’s treatment resistant you can’t do anything for it”.Struggling Striving Surviving 105 (168). well go ahead mate and look at the inside. like I’ve been told by doctors that it’s very hard to treat. “I’m sorry madam. (a) Feeling inferior: Stigma occurred with being diagnosed and labelled as inferior: “I was a bit shocked. I got told that a combination of therapy and medication would be best.
attention seeking. Consequence: increased difficulty in striving for autonomy to overcome being vulnerable because of feelings of shame. Another stigmatising label. As this participant explained: I used to hate the label attention seeking. Another participant explained .106 Dr Jenny Tohotoa any. the people [staff ] see you as being attention seeking and they put guilt on me” (P7). As a consequence: “You’re a bit scared cos [because] you know the way they’re [mental health staff ] going to be looking at you because they see me as this personality disorder thing” (P4). you seem to think that I’m the problem here (P2). what about the bastards who’ve done all this to me! Hello. “When I’ve presented at hospital with self harming. in fact I don’t deserve any treatment and I’m going ‘maybe that’s why I’ve never had any treatment” (P2). even other consumers stigmatise against it” (P2). but you don’t seem to see that. cos [because] it was so far from the truth. (b) Feeling victimised: This participant went on to describe one of her experiences of feeling victimized: You land up in hospital and the staff sit there saying. You feel such shame at what you’re doing and then you have to go and confess it to someone to get treatment. For example. I think. “you need to change your attitude”. (c) Having a label: Participants talked about other mental health consumers stigmatising against the label of BPD and subsequently against them: “I just hate that label [BPD] because it’s a stigmatizing label. guilt and anger. It’s certainly not the attention you want (P6). I’m on the bottom of the pile in the system. Continuing with the theme of stigma and discrimination a consequence experienced by one participant was her sense of injustice in mental health facilities: “They [health professionals] don’t realise how much stigma they dump on you. in particular upset the majority of participants who felt most aggrieved by the label because they believed it to be untrue. I think my attitude and reaction is frigging normal. “What the fuck are you talking about. participants said that health professionals labelled self-harming as attention seeking. I still hate it.
9. and that will come out in court” (P2). judgemental and rejecting of the patient with borderline personality disorder and used terms like manipulative and attention seeking to describe them (170). but we’re not going there That’s it you see. When I have normal periods they’re lovely. The stigma continued in the law courts and as a result of the diagnosis cases were dismissed: “It’s a Supreme Court case the lawyer told me.3. In support of the negative effect of labelling on the participants. participants were accused of not being able to handle it: “[They said that] because of my mental illness. or I wouldn’t have got in. When asked what would be helpful to her. .Struggling Striving Surviving 107 “[having a BPD] is very debilitating and it’s certainly not to seek attention. cos [because] I’d been rejected before” (P6). you’ve got a mental illness. In addition.1 Formal support Formal support included the support or lack of support from health professionals and the impact that support or lack thereof had on the participant’s striving for autonomy to overcome being vulnerable. unintentionally. Similarly. 9. apologise to me. in another study by Nehls (2000) concerned with recovery and empowerment for people with BPD. (d) Discrimination: Another participant disclosed her fear of discrimination in the workplace: “I never told anyone [at my current workplace] about my mental health history. Not to be so blaming” (P2). “Apologise.3 LEVEL OF SUPPORT The third condition to influence the basic social psychological problem of being vulnerable and the basic social psychological problem of striving for autonomy was level of support. Lewis and Appleby (1988) in their study found that psychiatrists were pejorative. I couldn’t handle it” (P2). The diagnosis of BPD was experienced as a pejorative label—a label that perpetuated a sense of being marginalised and potentially mistreated (29). apologise and say to me they got it wrong. the participants under study believed that service providers held preconceived and unfavourable opinions of people with BPD. one participant stated she would like health professionals to. I wish they’d stay there all the time” (P2).
I can’t tell them what I’m feeling. She went on to express the need for staff to be more proactive: I want to be able to have a worker. I can’t tell them. cos [because] usually when I’m in that place. What bloody use is that? (P2) . Not to be turned away and taken seriously. like the Salvos or the Samaritans. a case worker. who see me as a person first. The following participant expressed a sense of positive support from health professionals and feeling validated in her distress: “[They take me seriously] and that emphasises the seriousness of what I do. nurses whoever it happens to be. for her. that don’t see me as a diagnosis that’s got a name attached to it (P4). and they help sometimes” (P9). not just my psychiatrist. Being assigned a case worker who is available when needed would increase support and reduce the participants identified frustration. she’s booked up in advance so you can’t see her.108 Dr Jenny Tohotoa 9. angry and feeling in limbo for ongoing follow up care. When I’m upset I find it difficult to say exactly what I want or what I need. “Sometimes I ring the Help Line.3. and under the term clinicians I’m using psychologists.1. to have a management plan in place. to avoid confusion and to give support for both the staff and herself when she presented to hospital for either self-harming or suicidal ideation: Having a management plan is useful but it’s open to interpretation. so they need to ask specific questions. cos [because] I’ve been told my psychiatrist is my case worker and she’s only there once a week and you can’t get hold of her. I just know that I’m unsafe (P7). One participant found the crisis telephone lines were very useful. social workers.” (P9) The next participant explained the importance. Another participant described being validated by health professionals: What has been helpful has been finding clinicians.1 Positive formal support Formal support was recognised by participants to include volunteer services as well as hospital staff.
Most of the nurses come up to you. .Struggling Striving Surviving 109 The same participant was able to compare the lack of outpatient support to the generous inpatient support and question a healthcare service delivery that is so dissimilar: They [nursing staff ] are so good and it made me aware that they’ve [mental health inpatient unit] got the staff that they’ve had ever since that place opened. GP’s also often seek mental health advice and support. The ability of health professionals to empathise and engage with the participants was seen by the participants as essential to strive for autonomy to overcome being vulnerable. and they’re very pro-active and they’re very sensible. they come up and ask you if you want to see them during their shift. but find it sometimes difficult to access. Supporting health professionals as well through education is important as not only do the consumers need support from health professionals. it would be wonderful (P2). the way they treat you in there. Being supported both informally and formally was identified as vital to the participant’s striving for autonomy to overcome being vulnerable but unfortunately the support was not always available and left the participants continuing to struggle to survive. If that kind of thing could be on the outside. like you always get to talk to someone. It’s amazing.
According 110 .1. 10. a discussion on the treatment modalities for BPD including Linehan’s (1993) Dialectical Behavioural Therapy (38) and Young’s (1994) Schema Therapy (174) will be presented. commonly known as the Hierarchy of Needs (171).1 THE FINDING OF STRIVING FOR AUTONOMY TO OVERCOME BEING VULNERABLE WITH OTHER RESEARCH FINDINGS AND THEORIES The discussion outlines the similarities or differences of relevant scientific literature with the finding of striving for autonomy to overcome being vulnerable. In addition. These reviews include Maslow’s (1954) theory of human motivation. further theories and research findings relevant to the findings in this study are presented and compared with the identified categories in this thesis. This comparison highlighted that many components of the findings in this study had been documented in existing literature but that the multi-dimensional experience of managing life with a BPD in Western Australia had not been presented previously. Although literature has been presented throughout the chapters of this thesis.Chapter Ten The final objective of this book was to contextualise the finding of striving for autonomy to overcome being vulnerable within the relevant scientific literature.1 Maslow’s Hierarchy of Needs Striving for autonomy to overcome being vulnerable had similarities with Maslow’s Hierarchy of Needs first described in 1954. Erickson’s (1963) eight stages of human development (148) and Attachment Theories developed by Bowlby (1969) (172) and Ainsworth. Blehar. Waters and Wall (1978) (173). 10.
As postulated by Maslow. symmetry and beauty. deficiency needs and growth needs. detailed in the basic social psychological problem of being vulnerable to those described in level one and occasionally level two of Maslow’s hierarchy of needs. Maslow’s four growth needs were (1) Cognitive needs: to know. participants were unable to reach the higher growth needs and remained vulnerable and at the mercy of their dangerous environment. bodily comforts to (2) Safety/security needs: out of danger. with each stage being reached as the previous stage had been completed. connect to others up to (4) Esteem needs: to achieve. Unable to manage the experiences associated with these unmet needs led to participants feeling isolated. gain approval and recognition. participants described similar experiences. help others to find and realize their potential. thirst. as participants began to make changes to their lives. Although participants mostly had their physiological needs met. (2) Aesthetic needs: seeking order. and (4) Self-transcendence needs: to connect to something beyond the self. . Using data from the current study.Struggling Striving Surviving 111 to Maslow (1954). to (3) Belongingness and love needs: be acceptable. As the participants under study engaged in the basic social psychological process of striving for autonomy in chapter six and seven there was significant movement according to the theory by Maslow that related to belonging and self-esteem needs. reading and researching their disorder. When participants reached their turning point. Several participants described their constant fear and lack of safety in both their home of origin and in other environments making feeling safe and secure impossible. they were unable to feel safe and secure in their abusive environments as revealed in living in a dangerous world in chapter four. Participants began to manage being damaged that occurred during their childhood by seeking and finding a measure of safety and security. Many of the participants described an increased ability to appreciate simple things like the pleasure of gardening. alienated and unaccepted by society. to understand. they experienced a greater sense of the first growth level and sought understanding of themselves with therapy. during their life an individual progresses through two distinct human needs. The deficiency needs existed on four levels moving from the lowest (1) Physiological needs: hunger. This was assumed to be a progression. (3) Self-actualization needs: to find self-fulfilment and realize one’s potential. by finding a sense of self they gained insight and an increased ability to connect to others and search for meaning to their lives.
guilt. Erikson postulated that life consisted of eight stages that extended from birth to death. (b) Stage two: self-esteem versus shame. At the end of the process. In chapter four. Occurring between age three and five. Occurring between 18 months and three. (a) Stage one: trust vs. The unloving. For those participants who were not being abused at this stage. most of the participants were at level one of the growth levels as postulated in Maslow’s hierarchy of needs and moving slowly forwards. the . abusive home environments did not allow for self-expression and participants talked about being beaten if they cried and how they learned to survive. This stage was relevant to most of the participants and reflected the source of the identified basic social psychological problem of being vulnerable. Most of the participants expressed a lack of self-esteem and overwhelming sense of shame in chapter four. several participants related their difficulty in trusting not only themselves but also others and this was connected to being damaged by the abuse they experienced. 10. The stages of significance to participants in this study were stages one to six.1. Sexual abuse was still occurring for some of the participants and this stifled the opportunity to express themselves and they were more interested in safety and finding some solace from their dangerous environment.2 Erik Erikson’s eight stages of development Striving for autonomy to overcome being vulnerable also showed similarities with the developmental stages outlined by Erik Erikson (1963). This was an enormous step forward for several of the participant’s who had been unable to experience any positive emotions and had had difficulty trying to envision a different life for themselves. Usually occurring before age 2. (c) Stage three: initiative vs. Participants experienced more guilt than initiative and expressed their sense of confusion and despair that they still weren’t safe. so hardly surprising that mistrust resulted and became an enormous obstacle to overcome.112 Dr Jenny Tohotoa and experiencing pleasure when creating something for themselves or for others. Participants described memories of sexual abuse whilst still infants and it was the beginning of a childhood of extreme vulnerability and danger. mistrust.
kept most of the participants from exploring and developing initiative. and how to rectify the damage from their childhood. the commencement age of stage seven. All of the participants under study experienced role confusion as described in chapter five and many of them started to react to being damaged with drug and alcohol use and abuse in an effort to escape their emotional and physical pain. Self-harming behaviours became more frequent as life became more intolerable and their vulnerability increased. often the marriage was unsuccessful and ended in separation or divorce. they retained the unresolved feelings of inadequacy and inferiority that led to problems with competence and self-esteem.Struggling Striving Surviving 113 lack of emotional support and the conditional care given. (f ) Stage six: intimacy and solidarity vs. Participants expressed their sense of confusion with their lives and what was happening to them as they struggled to connect. Occurred between the ages of twelve and eighteen. . role confusion. Participants talked about their need for closeness and stability. inferiority: Occurred during school years As many of the participants under study were unable to gain the developmental milestones of stages one to three. so incorporated all the participants under study. most participants were failing to gain mastery over any of the stages. Although several of the participants got married. This left them ill equipped to strive for autonomy to overcome being vulnerable. isolation. Many of the participants described their sense of isolation and loneliness and consequently not being able to connect. but finding their inability to communicate and their fear of intimacy a barrier to a successful relationship. The long-term effects of not achieving the developmental skills at this stage led most of the participants to academic failure and a continued lack of self-regard. but saw them working towards a greater understanding of why that was. All of the participants found themselves seeking help and support at this stage and the basic social psychological process of striving for autonomy to overcome being vulnerable began during this developmental stage. If you used Erikson’s developmental stages as a measurement of progress for the participants under study. All the participants were actively engaged in some form of self-discovery and moving towards an increased level of competence of life skills. (e) Stage five: identity vs. (d) Stage four industry vs. Most of the participants in the current study were younger than thirty-five. Occurred from age eighteen to thirty five.
Blehar. Attachment is the strong bond that develops between a baby and parent/caregiver. Lack of trust.114 Dr Jenny Tohotoa 10. insecure attachment puts the child at risk for being diagnosed with a mental disorder (173). The concept involved parents/caregivers developing a consistent. Following on from Bowlby’s work. and the attachment pattern becomes a self-fulfilling prophecy and the child is trapped in a circle of despair (p. (a) anxious-avoidant attachment—when the child cannot rely on the caregiver and expects rejection.3 Attachment Theory Striving for autonomy to overcome being vulnerable also highlighted many of the developmental issues raised in 1969 by Bowlby who developed the attachment theory to account for the behaviours babies displayed in order to get their needs met (172). According to these authors. Waters and Wall (1978) proposed three insecure attachment styles that can occur as a result of living in a dangerous world. as a secure base across time and distance. constant fear and ongoing anxiety led the participants to doubt both themselves and the actions of others They talked about growing up in an environment that did not meet any of their basic needs . All of the participants under study experienced an insecure attachment arising from living in a dangerous world with the subsequent sense of being vulnerable. like the young of most animals was equipped with a set of in-built behaviours to keep the parent or caregiver nearby.1. 359). Ainsworth. (b) anxious-ambivalent attachment—when the caregiver responds in an aloof manner leaving the child uncertain and unable to connect. Their environment was often abusive and did not foster warm. thereby increasing the chances of being protected from danger. Ainsworth (1992) later proposed four categories of attachment style (175). Maternal or caregiver abuse and a lack of emotional security destabilised their ability to have a secure attachment. These were. and (c) disorganised attachment—when the child lacks a consistent attachment model and randomly chooses attachment methods to get their needs met. as all the participants under study had experienced being damaged and developed being vulnerable as a result. No one in the current study had a secure environment allowing for attachment to occur. He believed that the human baby. providing the baby with emotional security. sensitive and caring response to the child and hence an enduring affectionate bond that would enable the child to use this attachment figure. loving interactions: there was little positive role modelling and self worth was diminished as described in chapter four.
Participants talked about their difficulty making friends and the lack of intimate relationships in their lives. To manage being vulnerable participants described their attempts to escape through alcohol and drug use. this increased their vulnerability to exploitation and further abuse. allows them to formulate how acceptable or unacceptable they are in the eyes of their attachment figures (i. Many of the participants under study reported episodes of acting out and attention seeking behaviour . they experienced a fear of intimacy that led to them distancing themselves from others which in turn gave rise to feelings of isolation and abandonment. sexual abuse. The feedback they receive from these interactions. emotional abuse and neglect. Striving for autonomy to overcome being vulnerable has similarities with Cicchetti and Toth’s (2005) study that identified child maltreatment as one example of a toxic environment that posed considerable risk for so-called abnormal development to occur across diverse biological and psychological domains.2 A comparison of striving for autonomy to overcome being vulnerable with Cicchetti and Toth’s (2005) “Child Maltreatment”. Participants under study talked about their desire for acceptance. their self-image). 10. on the other hand.e. The participants in the current study described how they had tried to escape and learn to manage living in a dangerous world in the basic social psychological process of striving for autonomy. Child maltreatment is commonly classified into four main types: physical abuse. Similarly.(2003) found that children construct “internal working models” of their attachment figures out of their interactions with their caregivers (176). It also led to an inability to trust that led to isolation and feeling alienated. Where is the justice for the “victim”? In this damaging environment learning to survive was the first stage of the basic social psychological of being vulnerable for the participants under study and their vulnerability was displayed by their insecure attachment style. were allowed to carry on as if their actions were perfectly all right. Cicchetti et al.. However.Struggling Striving Surviving 115 and provided no safety. They felt punished for not meeting parental/ authority expectations whilst the perpetrators. Participants in this study were exposed to all of these abuses as explored in the first stage of the basic social psychological problem of being vulnerable. wanting to belong and unable to connect to others that led to their fear of never being acceptable.
for the participants it was their only way of attracting any response for their continuing distress.3 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with McDonald and Morley’s (2001) “Shame and non-disclosure: A study of the emotional isolation of people referred for psychotherapy. expression and understanding of emotions (176). Maughan. They create defences that include acting out. Massie and Szajnberg (2006) found that children respond to abuse and neglect with many distortions of emotional development. Maltreated children exposed to damaging environments were found to have difficulty in the recognition. 2003). and Bruce. These figures are a disgrace and a reflection on the economically driven government and subsequently a healthcare system that fails to address effectively the precipitating problems of poverty. A similar finding by Cicchetti. 10. From the Australian Institute of Health and Welfare report of 2002-2003 there was one child abused or neglected every 13 minutes. an increase of 42% over the past decade. mistrust. Toth. pain.” Striving for autonomy to overcome being vulnerable found most participants struggled with connecting as a result of living in a dangerous world. Given the dangerous environment they lived in. all participants experienced severe maltreatment during their childhood and adolescence that damaged them with similar consequences. In the current study. Whilst this behaviour is frequently deemed abnormal by health professionals. and loneliness (142). shame. denial. anger. apathy and confusion to manage over stimulation. Rogosch. Similarly. participants expressed their fear of self-expression and their fear of reprisals if they voiced their needs or wants. particularly negative ones in a menacing environment. The cost of child abuse in Australia is around $5 billion per year with costs expected to rise as the number of child abuse cases increases (AIHW. The participants under study described incidents of hyper vigilance and fear of anger which resulted in difficulty emotionally connecting to others.116 Dr Jenny Tohotoa to provide the security and stability they needed for survival. Participants talked about a lack of communication within their . uncertainty. threatening. inadequate childcare provision and a failure to value and promote the importance of good parenting and the ramifications when this is done poorly. fear. or even dangerous to discuss feelings and emotions. (2003) found children may learn that it is unacceptable.
not being acceptable. they spoke about their being labelled as “attention seeking” and the distress that label caused them. and thus constitutes the essential pain. Participants under study expressed their concerns about not being seen and feeling ignored and judged when they presented to the Emergency Department for treatment. This included not disclosing that were still using drugs and alcohol. with an emphasis on not “fitting in”. the poor self-image and their heightened sense of inferiority as they strove to overcome their vulnerability and move towards autonomy. Self-harming behaviours speak very clearly and loudly about distress. or falling short of a cherished ideal” (p. the fundamental disquieting judgement that we make about ourselves as failing. blaming. Supporting these findings. They described in chapter six how staff were unable to understand their underlying distress expressed in self-harming behaviours. flawed. useless and hopeless was the bottom line for most of the participants in this study and they battled with the ramifications of that. The fault does not lie with participants for being ‘unable to articulate their distress’. Several of the participants under study described the shame they experienced when self-harming behaviours brought them to the attention of mental health professionals. 82) (178). McDonald and Morley (2001) found that emotional isolation might be one reason that participants in their study were distressed (177). The study identified that shame was accompanied by a number of factors which implied negative self-assessment and the expectation that others would respond by labelling. inferior to someone else. both nonverbal expressions and self-report have been found to predict later self-injury in BPD (181). unworthy of the praise or love of another.Struggling Striving Surviving 117 family of origin and continuing into their adult life. The onus is on health professionals to understand. judging or blaming paralleled the experience of the current participants who expressed great distress at the thought of emotional disclosure. judging and disregarding the individual’s true concerns by attempting to falsely reassure them. This study has shown that . They were afraid of further reprisals adding to being damaged. 4) (177). worthless. give them unhelpful advice or by being unwilling to pay them any attention (p. Shame associated with feeling inadequate. The fear of labelling. 179) and shameful beliefs about oneself have been correlated with BPD features (180) Shame. Morrison and Stolorow (1999) stated: “Shame can creep into the very core of our experience of ourselves. the lack of self-esteem. Similarly. Chronic shame has been observed clinically as an emotion that is linked to problems with emotional dysregulation in BPD (38.
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shame is not pathologic, but rather a normal reaction for the participants that has been turned into a ‘sign and symptom’.
10.4 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with studies on self-harming Rosenthal, Cukrowicz, Cheavens, and Lynch’s (2006) “Self-punishment as a regulation strategy in BPD.”
Striving for autonomy to overcome being vulnerable also had similarities with the work of Rosenthal et al. (2006) who examined whether individuals with BPD would report higher use of self-punishment as a thought control strategy than comparison groups. They write that self-punishing behaviours can be conceptualized as self-invalidation and may take the form of a variety of behaviours, both overt (e.g., self-injurious behaviour) and covert (e.g., self-critical thinking) (182). In addition, these authors outline that individuals who chronically punish themselves in response to unpleasant internal experiences may do so as a means of self-verification (p. 234) (182). Participants in the current study described in Chapter four in the section on the loss of self, their need to ‘feel real”, their fear of rejection and abandonment and their use of self-punishment, to often self-soothe. Other experiences identified by the participants in this study included their sense of “being bad”, “needing to be punished”, feeling “worthless and useless”. Participants indicated that this led to ambivalence with living. In the development of the basic social psychological problem of being vulnerable, the participants related their use of alcohol to both avoid life and yet also to engage in life, by being one of the “group”. It included a way of validating their existence, a way to be seen and cared for, a form of self-punishment and sometimes as a pseudo-suicide attempt. They talked about escaping with drugs and looking for love through indiscriminate sexual liaisons. Unlike a study by Bijttebier and Vertommen (1999), where BPD symptoms were described as being associated with higher avoidance/escape responses, escaping from dangerous circumstances was adaptive for the participants under study (183). As the participants under study engaged in the basic social psychological process of striving for autonomy their self-harming, self-punishment decreased and they were able to begin to connect to themselves and others. It was directly related to them creating a safer environment.
Struggling Striving Surviving
10.5 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with the current models of treating people with BPD.
Whilst striving for autonomy to overcome being vulnerable many of the participants engaged in some form of therapy or treatment. Participants described being prescribed anti-depressants, mood stabilizers, anti-anxiety medication and anti-psychotics in an effort by health professionals to treat the symptoms of depression and despair. The American Psychiatric Association (APA)(2001) have developed guidelines for treatment of BPD and whilst they are not intended to be a standard of care, they recommend that psychotherapy represents the primary treatment for this disorder and that adjunctive symptom targeted pharmacotherapy can be helpful. In the basic social psychological process of striving for autonomy, participants experienced a turning point that brought them into contact (usually) with mental health services. They found themselves referred for ongoing psychological support and treatment to either a clinical psychologist, a Dialectical Behaviour Therapy (DBT) program or the “Changes program for people with BPD” depending on their availability of time to attend and their commitment to gain insight and mastery of themselves Many of the participants praised the respective programs they attended and all of the participants experienced a subjective sense of improvement in both their sense of self and in their ability to connect with others. They talked about a renewed interest in their environment and a decrease in their self-harming behaviours. The goals of treatment for BPD need to address the dangerous environment and enable the consumers to gain safety to decrease the disorganization and instability in self-image, mood, behaviour and close personal relationships. Training in ways to reduce self-destructive behaviour and improve tolerance for frustration; learning to modify mood swings; the development of more stable interpersonal relationships; a sense of one’s own strengths and limitations and learning to be alone. 10.5.1 Dialectical Behaviour Therapy Marsha Linehan (1993) developed DBT based on the principle that BPD is result of an emotionally vulnerable individual growing up in an invalidating environment (184). The dialectical approach to understanding and treatment of human problems involve techniques
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for achieving change balanced with techniques of acceptance, problem solving is surrounded by validation and confrontation is balanced by understanding DBT integrates proven techniques from cognitive and behavioural therapies within a philosophical and theoretical framework for understanding borderline pathology Its theory and practice borrow from four different orientations: biological, social, cognitive-behavioural and spiritual (184). DBT is a four-stage treatment. In stage one, the primary focus is on stabilising the patient and decreasing suicidal, therapy—interfering and quality of life interfering behaviours Stage two is related to treating problems of past trauma, stage three places an emphasis on self-esteem and the effective management of daily living and stage four sees the individual as seeking to develop the capacity to enjoy life (185). There are only two Dialectical Behaviour Programs [DBT] that follow the Marsha Linehan (1993) School of therapy in Western Australia (38). Women [only] attend twice a week for 12 months and learn the four core principles of DBT: mindfulness, emotional regulation, interpersonal communication and distress tolerance. There is currently a six-month wait list for these programs. Royal Perth Hospital used to run the only Changes program in Western Australia and it incorporated DBT with practical skills sessions such as time management, budgeting, anger management and cognitive behavioural therapy. Anyone with a personality disorder could be referred to this program [it is not gender specific] and people attend five days a week with a commitment for 12 months. The therapeutic outcomes which included increased well being and sense of self were found to be beneficial to the participants under study. 10.5.2 Schema—focused therapy Schema-focused therapy was developed by Young (1994) for consumers who did not respond to conventional cognitive behavioural therapy. Schemas can be thought of as central and enduring themes in a person’s life and reflect difficult to change views of ourselves, others, and the world (174). Young (2003) identified disconnection & rejection leading to schemas of abandonment/instability, mistrust, emotional deprivation, social isolation/alienation, defectiveness/shame, social undesirability, and failure to achieve. This concept of maladaptive schemas in schema-focused therapy contrasted with the experiences of participants in this study who described living in a dangerous world and
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being abandoned, neglected and abused, which in turn fostered mistrust and a self impression of being unlovable and unacceptable. Schema-focused therapy utilises experimental, cognitive, behavioural and interpersonal (object relations) techniques. It incorporates the use of imagery and role playing, empathic reality testing that acknowledges and validates distressing feelings, and challenges and modifies negative thoughts and behaviours. Schema-focused therapy deals with lifelong patterns rather than current situational crises, and the main goals are involved with the identification of early maladaptive schemas, changing dysfunctional beliefs and building alternative beliefs, breaking down maladaptive life patterns and changing coping styles, providing skills to create adaptive thinking and empowering consumers and validating their emotional needs that were not met. None of the participants under study had experienced schema-focused therapy. 10.5.3 Supportive Psychotherapy Pinsker (1997) defined supportive therapy as a treatment that emphasised building self-esteem (feeling more positive about oneself ), reducing anxiety and enhancing coping mechanisms (using more adaptive defences such as suppression or intellectualization, rather than using regression, splitting or projective-identification) (186). It is conversational in style and commonly uses techniques such as clarification, suggestion, praise, education and examination of the influence on present life patterns originating in the past. The main goal of supportive therapy is the prevention of suicidal crises by helping patients develop more adaptive alternatives (187). Similar to DBT, the early stages of treatment focus on reducing suicidality and self-injurious behaviour. Other aspects of treatment include dealing with the derealisation/dissociation, idealization/ devaluation, harsh self-evaluation, and anxiety and depression. Later treatment focuses on helping the patient develop positive aspects of their life—working on relationships, improving work functioning and establishing and maintaining positive feelings about themselves (187). Utilising the theoretical concepts of attachment theory in a supportive psychotherapy environment Sherry (2007) identified self reported positive changes with social functioning and a reduction of suicidality and self harming (188).
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10.6 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with McDonough, Wynaden, Finn, McGown, Chapman, & Hood’s (2004) “Emergency department mental health triage consultancy service: an evaluation of the first year of the service.”
Parts of Striving for autonomy to overcome being vulnerable has comparisons with McDonough, et al., (2004) who identified the positive impact of a specialist mental health nurse in the Emergency Department and on the patients who attended with deliberate self-harm and other mental health problems. Some participants spoke in Chapter six about feeling ashamed, humiliated and disrespected by their encounters with some of the emergency staff when they looked for understanding of their actions. They talked about the judgmental and dismissive attitude and stigma they experienced whilst seeking help for their distress. Others related their positive experiences and expressed surprise at being treated as “a person in need”. They identified an atmosphere of acceptance and did not feel judged. They discerned a willingness on the part of the staff to engage with them and did not feel intimidated and fearful. Similarly, McDonough, et al., (2004) also described an increased sensitivity in the general staff in the Emergency Department to deliberate self-harm patients and attributed it to the role modelling of the specialist mental health nurse attached to the Emergency Department (189). This practice of having specialist mental health staff in the Emergency Department has increased to twenty four hours a day and includes all major teaching hospitals in Perth as a result of McDonough, et al (2004) pilot study results, and can only improve the outcomes for the participants experiencing and presenting with BPD (189).
10.7 Summary of the discussion
The discussion focused on comparing the finding of striving for autonomy to overcome being vulnerable with other relevant theories and research and found that many aspects of the experience of managing life with a BPD in Western Australia were encountered by other consumers with a BPD outside of Western Australia and reflected the current thinking on the management of BPD. The similarities of the reviewed literature and the findings in this study add to the credibility,
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trustworthiness, and transferability of the findings of this study. In addition, the comparison with existing literature also revealed that the findings in this study of striving for autonomy to overcome being vulnerable described the multidimensional experience of how people diagnosed with BPD managed their lives, which had not previously been documented in the literature.
1. health professionals. International studies of treatment for BPD in therapeutic units has shown a marked decrease in self-harm/suicidal behaviours. Each of these initiatives will now be presented. and the general population. 11. 191) but these interventions are not easily available in Western Australia due in part.1 Initiatives directed towards government planners in the Health Department With regards to health care in striving for autonomy to overcome being vulnerable the participants need to be supported in both an inpatient and outpatient capacity. teachers. day care personnel. especially mental health professionals. to economic rationalization. The applications are described in terms of recommendations needed to help people diagnosed with a BPD to better strive for autonomy to overcome being vulnerable.1 IMPLICATIONS OF THE FINDINGS This section presents the applications of the finding of this study of striving for autonomy to overcome being vulnerable. There is no identified specialist BPD unit within Western Australia even though the risk of completed suicide for this consumer group is significant at 9%-10% (109). universities.Chapter Eleven 11. Several researchers have reported considerable improvements in specialised units run on psychodynamic (190) or cognitive-behavioural or dialectical behavioural lines (184. 124 . and also a substantial reduction in service consumption and costs (193) (194). The target audience for these initiatives includes government policy planners in the health department. an increase in self-responsibility and an increase in interpersonal relationship skills (192).
Davis and Youngren (1997) suggested that ideally. the remainder for short-term admission prior to linking in with the day program. The NHMRC will adapt the NICE guideline for Australian health-care settings with the assistance of a multidisciplinary guideline development committee. This can cause increased stress and frustration for consumers with BPD and often leads to them leaving the Emergency department without waiting to receive possible support or treatment. more conventionally ‘ill’ and easier to treat with medication. Five beds could be used for brief admissions. Under the present system of health service delivery. For brief therapies of up to 6 months’ duration and for longer term therapies of 2-5 years. who may be seen as more deserving.Struggling Striving Surviving 125 The allocation of resources for the treatment of mental disorders has favoured the needs of those with chronic psychotic disorders. . it would be economically viable and therapeutically valuable to have a specialised mental health unit in an authorised setting for the ongoing in-patient and outpatient needs of those people who suffer with and need treatment for a BPD due to being vulnerable as a result of living in a dangerous world. there is frequently no bed available in an appropriate setting (psychiatric unit) for the patient with BPD who is self-harming. Gunderson. in particular the NICE Guideline on the Treatment and Management of Borderline Personality Disorder (2009) (196). to allow for autonomy to develop further (195). In summary. Clinical Practice Guideline for the management of borderline personality disorder are currently under development in Australia The guideline will be developed in accordance with NHMRC standards and involve the review of existing evidence and international guidelines. a comprehensive service for patients with BPD should include facilities for brief hospitalization to provide safety in the case of feeling ambivalent about living. whilst there is usually a mental health liaison nurse in the Emergency Department of each of the major teaching hospitals. It can lead to being detained involuntarily because of perceived antisocial behaviour arising from their inability to wait. They may need to remain in the observation ward with extremely physically sick patients that utilise the majority of staff time and attention. This service delivery could be accommodated with an identified 6-8 beds within an authorised hospital with day patient facilities attached to run a group program for both brief and long-term therapy sessions on an outpatient basis.
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11.1.2 Initiatives directed towards health professionals, mental health professionals in particular. Several participants in this study disclosed their feelings of shame and inferiority with their inadequate parenting skills, and the overwhelming distress at losing custody of their children. Training for workers involved with mothers and children is needed to enhance the understanding of the long-term psychological and social impact of being damaged and living in a dangerous world and to help with striving for autonomy to develop means of support for both adult survivors and their children (146). Some of the participants reflected on the experience of their parents who had been sexually abused and the difficulties they had to protectively parent. Highlighting at risk mothers during antenatal follow up could be the first step in ensuring the pattern of non-protective, abusive parenting does not continue. Community child health nurses are in an ideal position to identify and flag at risk babies and mothers/caregivers, and offer the opportunity for them to obtain better parenting skills in order to understand how the child develops and to help ensure their child develops to their potential. Training and support for these staff is essential and mandatory reporting of suspicions of child abuse would further help prevent the creation of damaging environments. The participants in this study expressed their concerns about not being safe and feeling ambivalent about living. The primary difficulty for clinicians when treating people with a BPD is frequently the management of chronic suicidality and self-harming behaviour. For a person who is chronically suicidal, the desperate attempts to gain refuge from their pain can generate overly custodial interventions by health professionals that encourage further damage with a resulting helplessness and the removal of the client’s sense of self (197). The development of an adequate management plan involves a good understanding of the meaning of living in a dangerous world and what therefore, would be of most benefit to the client in the dual role of keeping them both safe and maintaining their sense of self. Training in empathy, increased listening skills and enhanced negotiation skills were identified by the participants under study as important for all health professionals working with consumers with BPD. The further damage health professionals can inflict on people with BPD has been recognised by participants and this needs to be addressed so that it does not occur. Together with participants, Barker (2001) talks about compassion and, what he calls participatory care or ‘caring with’ patients:
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We need to care about the person—which is the basis of our compassion, we need to show that by caring for the person when they are vulnerable, but the empowering basis of participatory care involves caring with. (p.234)(198).
Participants under study discussed both their positive and negative experience with staff in hospital in chapter six. Similarly, staff interviewed in the current study voiced concerns of not feeling supported in their workplace nor adequately trained to effectively cope and manage patients with BPD. Supporting the staff ’s view, Krawitz (2001) talked about BPD being one of the most difficult and challenging areas of mental health for staff,(180) whilst participants with BPD found it difficult for health professionals to provide satisfactory care. In summary, mental health professionals working with people diagnosed with BPD need to recognise the importance of striving for autonomy to overcome being vulnerable. Working within a multidisciplinary team that applies what participants have identified in this study with ongoing clinical supervision is important so that they learn what to do. Understanding of this fact and also showing empathy for the distress and torment people with BPD endure can often decrease the demeaning attitude from staff. Krawitz, (2008) found that it was possible through brief training to assist clinician positivity and to effect clinician attitudinal change when working with people with BPD (199). 11.1.3 Initiative directed towards universities Participants in the current study talked about their concerns about the lack of education that health professionals receive to help them with striving for autonomy to overcome being vulnerable and the unsympathetic and ignorant response from some medical staff. The current undergraduate programs in the health arena in Western Australia do not have enough information or training to work with people with personality disorders. None of those health professionals directly engaged with consumers who have BPD have sufficient exposure in their educational courses to the issue of BPD, particularly with how to help them to strive for autonomy to overcome being vulnerable. Basic counselling needs to be included in courses for all mental health and emergency department staff, and increased staff development workshops to gain the skills needed to work with people with personality disorders.
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This would enhance the positive experience for the consumers of these health care services as identified by the participants under study. Post-graduate courses in mental health have recently commenced at both Curtin and Edith Cowan universities and these are enabling those nurses interested in mental health an opportunity to specialise in the area. However, working with people with personality disorders requires an advanced level of training that is currently unavailable in Western Australia. A collaborative partnership between academic and clinical settings is suggested by Fineout-Overholt, McInyk and Schultz (2005) to promote practice based on research such as that revealed in this study (200). Using this research-based approach, a clinician’s expertise, and patients’ values and preferences, nurses and other health professionals can provide care that goes beyond providing care that prolongs being vulnerable due to living in a dangerous world. In summary, as BPD is seen in 10%-12% of mental health out-patient clinics and up to 20% in inpatient mental health units, anyone working in mental health will undoubtedly come into contact with these people and therefore added training time could be both beneficial to the clients with BPD. Healthcare that is research-based and conducted in a caring context, as shown in this study, leads to better clinical decisions and patient outcomes. 11.1.4 Initiatives for teachers and day care centre staff Participants talked about being damaged by sexual abuse occurring in their early childhood and school age years. From their experience, with one exception, no one noticed their response of reacting to the damage by trying to escape or even identified the existence of the abuse. Teachers and day care personnel are at the coalface for recognising being damaged and need training and support to enable them to act to provide a safe environment for children who are being damaged, maltreated and abused. The causative association between childhood sexual abuse and the development of BPD has been researched by many clinicians (90, 105, 109, 145, 195, 201) and reinforces the preventative emphasis for change. The link between childhood sexual abuse as a risk factor for suicidal behaviour in BPD was 10 times greater than for non sexually abused people (126). In summary, preventative measures must be given top priority. These could include training for adult carers to detect abuse and damage
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in children, promotion of community awareness to abuse in various media, newspapers, television, mobile phone messages, and internet self protection skills sites for adolescents. Public forums and conferences are needed to highlight the basic principles of protective parenting and protective care giving for children in an effort to decrease the development of another generation of people who will suffer with BPD, from living in a dangerous world. 11.1.5 Initiatives for the general population Participants expressed their concerns and distress about being stigmatized by the label “borderline” and a heightened community awareness of the suffering and trauma people with BPD experience could decrease the stigma. One initiative for the general population would be to increase the public’s awareness that people with BPD live in a dangerous world. During mental health week in 2005, there was a session on BPD by the Chief Psychiatrist, and was certainly of value to those attending. This was the first time the topic of BPD had been openly discussed and available for the general population to attend. In this study, I have shown that the general population needs to be educated on how they can improve their own attitude and behaviour towards people with disorders and how society, in this case the dangerous environment, can be changed to protect rather than abuse. Community resource centres and doctors surgeries could be the initial starting place for general population exposure on how to provide a safe environment and the ways in which family members and friends can support and assist the person to find help with striving for autonomy to overcome being vulnerable. Families of people with BPD often feel confused, frustrated and helpless and need help and support in understanding how best to support the family member with BPD. Strategies for dealing with issues such as the ambivalence of living could be invaluable to family members. In the U.S.A. the self-help group known as TARA NAPD (Treatment and Research Advancement National Association for Personality Disorders) provides a family support network, advocacy and online support for people to express their feelings and to share information about BPD. There is no such agency in Western Australia, which leaves the general population without the resources to learn more about how to support people with BPD to strive for autonomy to overcome being vulnerable.
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In summary, increasing community awareness of what it is like to be vulnerable and living in a dangerous world is the first step to decrease stigma and ignorance. People who are vulnerable due to living in a dangerous world can use all the help we can give them. They need our effort, our hope, and our willingness to support them (169). Lobbying for funding to promote awareness of what it is like to be vulnerable due to living in a dangerous world and developing self-help groups to help with striving for autonomy would increase tolerance in the general population. We can make the changes outlined in this study and make better connections generating optimism in place of pessimism for consumers, family members and health workers and by averting the psychology of blame.
11.2 LIMITATIONS OF THE STUDY
The participants of this study comprised of 9 self-selected people who had the diagnosis of BPD and two mental health staff who were employed in a mental health setting which included working with people with BPD. Whilst the sample size is reasonably small and could be considered a limitation, the diversity of the shared experience that enabled a core category to develop clearly ensured that the aspects of how people diagnosed with a BPD managed their life in Western Australia were represented and categories were expansive and saturated. Using qualitative research methodology could be seen as a limitation by some researchers, but was chosen to adequately represent the lived experience of people with BPD. Criteria for inclusion controlled for age which restricted the recruitment to adults only. Likewise speaking and understanding English limited the cultural diversity of participants in this study.
11.3 FURTHER RESEARCH
The findings of this study uncovered the multidimensional aspects of how people with a diagnosis of BPD manage their life in Western Australia. The finding of striving for autonomy to overcome being vulnerable revealed the basic social psychological problem experienced by people diagnosed with BPD and the process they engaged in to overcome this problem. While the findings of this current study add to the existing literature, further research is needed to fully understand the phenomenon of having a BPD. Research with adolescents would be a strong recommendation from
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the study given living in a dangerous environment becomes more serious the younger the victim. This research needs to focus on preventative strategies that include early identification of damaging environments and those children at risk within them. Research into how to change society to make it a safe place would then prevent deliberate self-harming behaviours and abandonment issues. Further research on the benefits of identified specialist units for treatment of people with BPD vs. treatment in the general public healthcare system could direct their striving for autonomy.
11.4 CONCLUDING STATEMENT
The objectives of this study were to explore and explain the way people with borderline personality manage their lives in Western Australia and to identify factors affecting that experience. The use of the grounded theory approach allowed the identification of a basic social psychological problem and a basic social psychological process, which was shared by the participants. Participants became vulnerable living in a dangerous world of abuse and neglect. Participants experienced sexual, physical, emotional abuse and were in a constant state of uncertainty, fear and confusion as to what was right and of what to do. Participants struggled to connect to others and felt different and alienated with low self-esteem and no sense of themselves. As a result of being vulnerable participants tried to escape with alcohol, drugs and deliberate self-harming behaviours. Striving for autonomy was a process that participants engaged in to manage their lives, to gain some insight into their behaviours and seek some safety and security. The experience of striving for autonomy consisted of a three-stage process. Stage one occurred predominantly in the time before the experience of a turning point, and participants engaged in the remaining two stages when they had realised that they could have more control over their lives and make positive changes in order to feel more connected to both themselves and others in their lives. Three conditions influenced the basic social psychological problem and process. These were influence/ impact of another existing mental illness; low threshold to stressors and level of support from family members and friends. The findings of this study will be of value to people diagnosed with a BPD, mental health professionals, health professionals in childcare and midwifery, the general population and government policy planners. The findings can be used in a variety of ways to facilitate people trying to manage their life with a diagnosis of BPD from being vulnerable through the process of striving for autonomy.
and symptom maintenance. Their journey is one of courage against the enormous obstacles of stigma. I am committed to breaking down the barriers of injustice and prejudice that abound with the diagnosis of BPD. and that they have not given up the fight for autonomy. I feel privileged that participants were able to share their life journey so far with me. I have great respect for and will continue to promote the huge potential for recovery not only for the participants but also for anyone who suffers with BPD.132 Dr Jenny Tohotoa BPD appears to have three possible long-term outcomes: remission of symptoms. in order that their experience is both positive and ultimately therapeutic. social learning and the avoidance of conflictual intimacy. How the participants under study manage their lives with a diagnosis of BPD can direct the appropriate treatment options to best suit individual needs. The mechanism behind the remission could include maturation. suicide. In conclusion. ignorance and intolerance. .
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Five (or more) of the following symptoms have been present during the same 2 week period and represent a change from previous 149 . American Psychiatric Association. other conditions that may be a focus of clinical attention Axis II Personality disorders. (p. The five axes included in the DSM-IV-TR multiaxial classification system are: Axis I Clinical disorders. psychosocial and environmental problems. Copyright 2000. The DSM-IV-TR is comprised of a multi axial assessment system. mental retardation Axis III General medical conditions Axis IV Psychosocial and environmental problems Axis V Global assessment of functioning The use of the multiaxial system facilitates comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions. 27) Mood disorders The DSM-IV-TR diagnostic criteria for Major Depressive Disorder A. and level of functioning that might be overlooked if the focus were on assessing a single presenting problem.Appendices Appendix 1: Diagnostic and statistical manual of the American Psychiatric Association classification of disorders (DSM-IV-TR) Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders.
g. not merely subjective feelings of restlessness or being slowed down) 6. C. The symptoms are not due to the direct physiological effects of a substance (e. D. E..g. hypothyroidism). at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. consider failure to make expected weight gains.g. feels sad or empty) or observation made by others (e.g.. occupational. Diminished ability to think or concentrate. nearly every day (either by subjective account or as observed by others) 9. 4.. The symptoms are not better accounted for by Bereavement. or a suicide attempt or a specific plan for committing suicide B. i. Depressed mood for most of the day. or other important areas of functioning. nearly every day. after the loss of a loved one.g. Insomnia or hyersomnia nearly every day 5. a drug of abuse. a change of more than 5% of body weight in a month). Psychomotor agitation or retardation nearly every day (observable by others. The symptoms cause clinically significant distress or impairment in social. 1. Significant weight loss when not dieting or weight gain (e. as indicated by either subjective report (e. or indecisiveness. can be irritable mood 2. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. the symptoms persist for longer than . or decrease or increase in appetite nearly every day Note: In children. Fatigue or loss of energy nearly every day 7. Recurrent thoughts of death (not just fear of dying). recurrent suicidal ideation without a specific plan. a medication) or a general medical condition (e. or almost all. The symptoms do not meet criteria for a Mixed Episode. nearly every day (as indicted by either subjective account or observation made by others) 3.. Markedly diminished interest or pleasure in all. appears tearful) Note: In children and adolescents.. activities most of the day.e.150 Dr Jenny Tohotoa functioning.
5. (p. Depressed mood for most of the day. mood can be irritable and duration must be at least one year. B.. for more days than not. in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode). . suicidal ideation. In addition. the disturbance is not better accounted for by chronic Major Depressive Disorder. after the initial two years (one year in children or adolescence) of Dysthymic Disorder. Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness C. Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significance signs or symptoms for two months) before development of the Dysthymic Disorder.e.Struggling Striving Surviving 151 two months or are characterised by marked functional impairment. or psychomotor retardation. 356) DSM-IV-TR diagnostic criteria for dysthymic disorder A. Presence. of two (or more) of the following: 1. During the two-year period (one year for children or adolescents) of the disturbance. while depressed. Note: In children and adolescents. In Partial Remission. morbid preoccupation with worthlessness. No major Depressive Episode has been present during the first two years of the disturbance (one year for children and adolescents). D. 6. there may be superimposed episodes of Major Depressive Disorder. psychotic symptoms. i. the person has never been without the symptoms in Criteria A and B for more than 2 months at a time. as indicated either by subjective account or observation by others. for at least two years. 4. or Major Depressive Disorder. 2. 3.
lasting at least one week (or any duration if hospitalisation is necessary). The symptoms cause clinically significant distress or impairment in social. The symptoms are not due to the direct physiological effects of a substance (e. 5.g. Increase in goal-directed activity (either socially.152 Dr Jenny Tohotoa E. 2. expansive.g.e. a medication) or a general medical condition (e.. or other important areas of functioning. During the period of mood disturbance. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder.. G. A distinct period of abnormally and persistently elevated. or sexually) or psychomotor agitation 7.g. 4. 3. or a Hypomanic Episode. feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas of subjective experience that thoughts are racing Distractibility (i.. B.. and criteria have never been met for Cyclothymic Disorder. engaging in unrestrained buying sprees.g. Inflated self-esteem or grandiosity Decreased need for sleep (e. F. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e. or foolish business investments) . There has never been a Manic Episode. three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1. attention too easily drawn to unimportant or irrelevant external stimuli) 6. 380-381) DSM-IV-TR Diagnostic Criteria for Manic and Hypomanic Episodes Manic episode A. such as Schizophrenia or Delusional Disorder. occupational. or irritable mood. a Mixed Episode. hypothyroidism). H. at work or school. (pp. a drug of abuse. sexual indiscretions.
(p. Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.g. electroconvulsive therapy.g. expansive.. hypothyroidism).Struggling Striving Surviving 153 C. E. a drug of abuse. lasting at least four days. The symptoms do not meet criteria for Mixed Episode. or to necessitate hospitalisation to prevent harm to self or others. The episode is not severe enough to cause marked impairment in social or occupational functioning.g. The symptoms are not due to the direct physiological effects of a substance (e. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others. 362) Hypomanic episode A. . F. a drug of abuse. B. a medication) or a general medical condition (e.. or there are psychotic features. light therapy) should not count toward a diagnosis of Bipolar I Disorder. a medication) or a general medical condition (e. [Same mood disturbances as in Manic Episode occur. E. and there are no psychotic features. A distinct period of persistently elevated. The disturbance in mood and the change in functioning are observable by others.g. D. medications. that is clearly different from the usual non-depressed mood. or to necessitate hospitalization.g.] C. or irritable mood. The symptoms are not due to the direct physiological effects of a substance (e. D. hypothyroidism).
The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia. Schizophreniform Disorder. single manic episode A. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia. The mood symptoms cause clinically significant distress or impairment in social. or Psychotic Disorder Not Otherwise Specified. Schizophreniform Disorder.g. or Psychotic Disorder Not Otherwise Specified. There has previously been at least one Manic Episode or Mixed Episode. Bipolar 1 episode. light therapy) should not count toward a diagnosis of Bipolar I Disorder. Delusional Disorder. (p. Currently (or most recently) in a Manic Episode. or other important areas of functioning. electroconvulsive therapy. Presence of only one Manic Episode and no past Major Depressive Episodes Note: Recurrence is defined as either a change in polarity from depression or an interval of at least two months without manic symptoms. medications. B. most recent episode manic A. occupational. B. Delusional Disorder. D. Bipolar 1 episode. 368) DSM-IV-TR Diagnostic Criteria for Bipolar 1 Disorder Variants Bipolar 1 disorder.154 Dr Jenny Tohotoa Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e. C. Currently (or most recently) in a Hypomanic Episode. most recent episode hypomanic A. .
The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia. Presence (or history) of one or more Major Depressive Episodes. (pp. Delusional Disorder. C. most recent episode mixed A. C. . or Psychotic Disorder Not Otherwise Specified. There has previously been at least one Manic Episode or Mixed Episode. Delusional Disorder. There has previously been at least one Major Depressive Episode. There has never been a Manic Episode or a Mixed Episode. Schizophreniform Disorder. or Psychotic Disorder Not Otherwise Specified. C. most recent episode depressed A. B. 388-391) DSM-IV-TR criteria for Bipolar II disorder A. B. B. Delusional Disorder. Currently (or most recently) in a Major Depressive Episode. Bipolar 1 episode. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia. There has previously been at least one Major Depressive Episode. Presence (or history) of at least one Hypomanic Episode. Manic Episode. C.Struggling Striving Surviving 155 B. or Psychotic Disorder Not Otherwise Specified. or Mixed Episode. Currently (or most recently) in a Mixed Episode. Schizophreniform Disorder. Bipolar 1 episode. Manic Episode or Mixed Episode. Schizophreniform Disorder.
E. F. or other important areas of functioning. hypothyroidism). The symptoms are not due to the direct physiological effects of a substance (e. Note: after the initial 2 years (1 year in children and adolescents) of Cyclothymic disorder. or other important areas of functioning.g. Manic Episode.g. the person has not been without the symptoms in Criterion A for more than 2 months at a time. Delusional Disorder.. or Psychotic Disorder Not Otherwise Specified. For at least 2 years. E. D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia. or Psychotic Disorder Not Otherwise Specified. 397) DSM-IV-TR Diagnostic Criteria for Cyclothymic Disorder A. The mood episodes in Criteria A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia. B. or Mixed Episode has been present during the first 2 years of the disturbance. a medication) or a general medical condition (e. During the above 2-year period (1 year in children and adolescents). The symptoms cause clinically significant distress or impairment in social. Schizophreniform Disorder.. 400) . there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II and Cyclothymic Disorder may be diagnosed). the duration must be at least 1 year. (p. the presence of numerous periods of hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. The symptoms cause clinically significant distress or impairment in social. Delusional Disorder. (p. C. occupational. Schizophreniform Disorder. No Major Depressive Episode. Note: In children and adolescents. D. occupational. a drug of abuse.156 Dr Jenny Tohotoa D.
C.. 4. or (2) if mood episodes have occurred during active-phase symptoms their . alogia. D. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance. Duration: Continuous signs of the disturbance persist for at least 6 months.e. or Mixed Episodes have occurred concurrently with the active-phase symptoms.. odd beliefs. each present for a significant portion of the time during a 1-month period (or less if successfully treated): 1. active-phase symptoms) and may include periods of prodromal or residual symptoms. academic. 2. Manic. B. or self care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence.e. Delusions Hallucinations Disorganised speech (e. 3.g. During these prodromal or residual periods. affective flattening. or occupational achievement). Schizoaffective and Mood disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive. one or more major areas of functioning. i. such as work. or avolition. unusual perceptual experiences).Struggling Striving Surviving 157 Schizophrenia DSM-IV-TR diagnostic criteria for schizophrenia A. 5. Characteristic symptoms: Two (or more) of the following. the signs of the disturbance may be manifested y only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e. Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behaviour or thoughts. interpersonal relations.g. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i. failure to achieve expected level of interpersonal. or two or more voices conversing with each other.. frequent derailment or incoherence) Grossly disorganised or catatonic behaviour Negative symptoms.
light headed. F. Paresthesias (numbness or tingling sensation) 13. Chills or hot flushes (p. 7. (p. 2.g. 432) . unsteady. in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: 1. or faint Derealization (feelings of unreality) or depersonalisation (being detached from oneself ) 10. 9. Code the specific diagnosis in which the Panic Attack occurs. 5. E.158 Dr Jenny Tohotoa total duration has been brief relative to the duration of the active and residual periods. Palpitations. the additional diagnosis of Schizophrenia is only made if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e. 4. Fear of dying 12. A discrete period of intense fear or discomfort. 6. a medication) or a general medical condition. a drug of abuse. Fear of losing control or going crazy 11. 3. 312) Anxiety disorders DSM-IV-TR general diagnostic criteria for panic attack Note: A Panic Attack is not a codable disorder. pounding heart. or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling of dizziness. Relationship to a Pervasive Development Disorder: If there is a history of Autistic Disorder or another Pervasive Development Disorder. 8.
Withdrawal. Important social.g. use the substance (e. Tolerance.. or recover from its effects 6. visiting multiple doctors or driving long distances).g. occurring at any time in the same 12-month period: 1. current cocaine use despite recognition of cocaine-induced depression.g. or recreational activities are given up or reduced because of substance use 7. The substance is often taken in larger amounts or over a longer period than was intended 4. as defined by either of the following: a) Need for markedly increased amounts of the substance to achieve intoxication or desired effect b) Markedly diminished effect with continued use of the same amount of the substance 2. chain-smoking). A great deal of time is spent in activities necessary to obtain the substance (e. as manifested by three (or more) of the following. leading to clinically significant impairment or distress. or .Struggling Striving Surviving 159 DSM-IV-TR general diagnostic criteria for substance dependence A maladaptive pattern of substance use. as manifested by either of the following: a) The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms 3.. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.. There is a persistent desire or unsuccessful efforts to cut down or control substance use 5. occupational.
Substance Intoxication or Withdrawal 2. The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced.g. Note: Do not include hallucinations if the person has insight that they are substance induced. Prominent hallucinations or delusions. D.g.160 Dr Jenny Tohotoa continued drinking despite recognition that an ulcer was made worse by alcohol consumption) (p. about a month) after the cessation of acute withdrawal or severe intoxication. or within a month of. The disturbance does not occur exclusively during the course of delirium. physical examination. or there is other evidence that suggests the existence of an independent non-substance induced Psychotic Disorder (e. a history of recurrent non-substance-related episodes). the symptoms persist a substantial period of time (e. Note: The diagnosis should be made instead of a diagnosis of Substance intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficient severe to warrant independent clinical attention. Medication use is etiologically related to the disturbance C. The symptoms in criteria A developed during. There is evidence from the history.. B. (p. 342) . or laboratory findings of either (1) or (2): 1. or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use. 197) DSM-IV-TR general diagnostic criteria for substance-induced psychotic disorder A. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance us (or medication use)..
work or other activities b) Often has difficulty sustaining attention in tasks or play activities c) Often does not seem t listen when spoken to directly d) Often does not follow through on instructions and fails to finish school work.Struggling Striving Surviving 161 Attention deficit/hyperactivity disorder DSM-IV-TR diagnostic criteria for attention deficit/hyperactivity disorder A. books. or is reluctant to engage in tasks that require sustained mental effort (such as school work or homework) g) Often loses things necessary for tasks or activities (e. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention a) Often fails to give close attention to details or makes careless mistakes in school work. or toys) h) Is often easily distracted by extraneous stimuli i) Is often forgetful in daily activities 2. Six (or more) of the following symptoms of hyperactivityimpulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity a) Often fidgets with hands or feet or squirms in seat b) Often leaves seat in classroom or in other situations in which remaining seated is expected . chores. Either (1) or (2): 1. or duties in the workplace (not due to oppositional behaviour or failure to understand instructions) e) Often has difficulty organising tasks and activities f ) Often avoids. pencils. dislikes.g. school assignments. toys.
Often has difficulty awaiting turn i. D. butts into conversations or games) C. or a Personality Disorder). academic.162 Dr Jenny Tohotoa c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults. at school [or work] and at home). or occupational functioning. Often blurts out answers before questions have been completed h. Mood Disorder. Some impairment from the symptoms is present in two or more settings (eg. (pp. may be limited to subjective feelings of restlessness) d) Often has difficulty playing or engaging in leisure activities quietly e) Is often “on the go” or often acts as if “driven by a motor” f ) Often talks excessively Impulsivity g. or other Psychotic disorder and are not better accounted for by another mental disorder (eg. Some hyperactive-impulsive or inattentive symptoms that cause impairment were present before the age of 7 years. Schizophrenia. Often interrupts or intrudes on others (eg. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder. F. There must be clear evidence of clinically significant impairment in social. Anxiety Disorder. 92-93) . E. Dissociative Disorder.
She has 3 adult children and 2 adorable grandsons. The book was written for health professionals. both as a nurse and a counsellor. Her leisure time activities include cooking. . It is a reminder of the incredible strength and persistence people can muster in their struggle to survive. people diagnosed with a borderline personality disorder and for anyone who lives with or cares for someone with borderline personality disorder. She lives in Perth. She has continued her pursuit of advocacy and equity for mental health consumers and currently works as a university researcher in mental health. creating mosaics and doing puzzles. It was also written to emphasise the need for greater empathy and sensitivity for people who have survived childhood abuse and betrayal. Australia with her husband. DR JENNIFER TOHOTOA has worked as a nurse in mental health for 30 years in both the public and private arena. reading. she specialised in the area of working with consumers who have a diagnosis of borderline personality disorder (BPD).T his book is dedicated to all those people who struggle with childhood abuse and betrayal and who continue to strive for autonomy. Over the last 15 years. It was written to enlighten health professionals and the general public to the “lived” experience of borderline personality disorder.
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