I had a chance to speak with Dr. Seth Axelrod on recovery and borderline personality disorder. Dr. Seth Axelrod is an Associate Professor of Psychiatry at Yale School of Medicine as well as the Dialectical Behavior Therapy Team Leader at the Yale-New Haven Psychiatric Hospital Intensive Outpatient Program. Each spring he also co-chairs a Yale conference on BPD that is co-sponsored by the Yale University School of Medicine, Yale-New Haven Psychiatric Hospital, the National Education for Borderline Personality Disorder, and NAMI-Connecticut. I would love to know your thoughts and comments about what we talked about.
Listen in the player below by clicking on the play button:
Dr Axelrod on the stages of recovery:
So in terms of how individuals get [to recovery], in my experience doing dialectical behavior therapy, individuals who are starting from a place where there might be a lot of out of control emotions and a lot of out of control behaviors and a lot of life chaos… the first piece of work is committing to some length of time of agreeing to work on making it better, work on collaborating in treatment and working with my team, that will put in X amount of time where they committing to working real hard and putting in regular attendance and we’re committing to work really hard and putting our full self into it and that together, working through this model, that after some length of time, that we can then kind of assess have we made progress.
And the point of that is for an individual who’s chronically miserable and chronically looking for ways to escape their life or their experience — to kind of put aside that decision that it might be okay to escape life — and say okay, let’s put some effort in seeing if we can make it better and see if that works.
In my experience you need a little bit of a window to work in order to make the progress. If it gets too tight, moment by moment, convincing the person to stay alive, without any kind of agreement that we’re going to see if we’re going to improve the person’s life, then it’s hard to see movement happen.
So I see it as my work to get that kind of commitment from an individual, to give a window of opportunity. Once that’s there, often the first order of business is helping people develop skills for just getting through life without the self-destructive behaviors, particularly the suicide and self-harm kind of behaviors that often show up.
A lot of that work is helping them arrive to the conclusion and get on board with the idea that it’s worth it to tolerate situations in order to then be able to buy time and get opportunities to start improving their life. So once you have a foundation of skills, which are essentially, I can get through life even when it’s extremely painful and things really aren’t functioning, things really are broken in their life but they have the tools to say, okay I can stay alive and stay in tact and put my energy into coping instead of putting my energy into suffering and doing things that would make it worse, make more problems.
That once they have that foundation, then the windows of opportunity for actually putting work into improving their lives get bigger, because the individual spends less time acting in crisis ways and end up having less proportion of their time where they’re kind of on the edge of are-they-going-to-survive-or-not because they have confidence they can survive.
At that point, from a DBT perspective, it’s loading up a lot of other skills, for being effective in communication and relationships, for learning about emotions and developing a new relationship with one’s own emotions, learning ways to manage one’s emotions, and tackling specific parts of their life where they haven’t been successful. We don’t see it as any fault of their own, necessarily, but whatever the circumstance is, that they haven’t been able to have stability in living, work or relationships. We start tackling those problems.
And gradually the person feels more competent dealing with the problems of life as they show up. The person starts seeing more successes in building or fixing things that are broken. And perhaps starts initiating working on plans, working on goals that have been stuck or really been put aside. And the person starts to develop confidence in their abilities and appreciation for their life — living in a way that’s consistent with their values, that’s consistent with their self-respect, that’s consistent with goals that they set for themselves.
And once the person is doing that, I think they are in recovery. They may still struggle with episodes of mood problems, they might, in my experience, still have very strong emotional sensitivity, they may still have times where their mind reacts with thoughts that can be very disturbing or get very rigid at times but, they’ve got tools for dealing with it.
They’ve got tools for taking that step back, for using supports that they’ve been building, more effectively using professional supports than when I first started working with them. And they see themselves on a task, living — participating in life. So that’s what I see in my experience of what is the process of moving towards recovery.
And for the people I’ve seen who’ve gone that far, I think I’ve seen a fair amount of acceptance — if this is as good as it gets, in terms of managing thoughts and emotions — that it’s worth having a life that way. It’s workable, if not perfect… having thoughts of suicide pop up, for example… it doesn’t have to mean that life is not worthwhile. I’d love to see it go further than that, where individuals don’t necessarily have to deal with thoughts and urges pop up or mood episodes. And hopefully will continue to do better.
Dr. Axelrod on the fear of recovery:
I think there are lots of reasons why that comes up. In the biggest picture of it, individuals have gotten this far in their life by responding to things the way they do. Whatever the behaviors are, no matter how destructive or self-destructive the behaviors are, this is what the individual has come up with to respond to the problems that life sends them, the emotions that they have… and one thing that I think gets lost a lot in talking about individuals with borderline personality disorder is that they are often criticized for their behaviors; criticized for reacting the way they do, and they don’t see it themselves.
And I think that these individuals who have problems with the way they are coping, the way they react and lose control, they’re aware of the fact that what they’re doing doesn’t work and they often have a lot of self-hatred and self criticism for being reactive the way they are, and yet, they haven’t found other things, other ways to cope. And when they try to cope in other ways, it has blown up.
Usually they’re attempting to do some kind of coping that they’re told to do, but it’s not, it doesn’t sufficiently meet their needs. When they’re having far more difficulty controlling their emotions than others and then they are told that they should control their emotions like others, and they try to do it, it fails.
I think that individuals with BPD have tried on their own, so many different ways to cope that fail over and over again, and they often been in many therapies that have failed over and over again. And so they cling to what they’ve got because at least it’s gotten them this far, at least it takes away the pain and the suffering in short term at least. While they are in misery, there’s a safety in that. And I think that general principle is true across any therapies where a person is having to change the way they are dealing with their problems and take on new behaviors.
New behaviors are uncertain. They don’t come with guarantees. Any specific, here’s something you can do differently, will become more or less successful, particularly when you’re learning it for the first time. In the process of learning there’s going to be mistakes and things aren’t always going to work out.
The thing that I try to help individuals see is that sticking to their old coping — if they go in that direction — the outcome is certain. Because they know from experience that responding the way they’ve been responding has lead them to misery. And if they continue to respond the way they’re responding and their life isn’t going to magically change around them, well they can expect that they can continue to be miserable.
So holding onto it leads to a certain outcome. But if they want to have a different outcome, if they want to have a their life improve and get better, it means letting go of that certainty and stepping into the unknown. And in DBT we call that willingness.
Willingness is when you can see what you’re doing or tempting to do doesn’t work; when you can see that there is another option to try that might work — not that it will work — but that it might work. Willingness is stepping into that new behavior to see what happens. And learning in the process of successes and failures — gradually moving forward, gradually doing things, gradually seeing your life improve — but there’s going to be lots of stumbles along the way.
AW: Willingness is almost like having the faith to put in the work that you need in order to progress on…
There’s a quote from Martin Luther King that I came across, that talks about faith, and I bring it up sometimes when I’m teaching about willingness… that faith is walking down a dark staircase not being able to see the next step.
I think that for an individual with BPD facing recovery, that’s what it is — taking that step, it’s putting trust into… if they’re working in therapy it’s putting trust in the therapist, in the therapy, and it’s terrifying because you can’t see; you can’t quite see the path. They just know that they don’t want to be where they are and we as therapists help orient them to keep their eye on the prize — where would they like to go with their life, where would you like to see your life move.
Dr. Axelrod on the future of research in recovery:
The thing that I’m aware of is that we have not even begun to know really what recovery is in terms of through research, in terms of empirical studies. There’s really only the very beginnings of research — nothing solid about looking at large numbers of individuals.
How many people go through therapies actually end up in recovery? How many people who don’t go to therapy end up in a state of recovery? What does recovery look like? I gave my description based on my clinical experience but we know from research, we know from the history of borderline that the difference between clinical impressions and reality from research can be greatly different.
Clinical impressions taught us for years and years that individuals with BPD don’t change and that the diagnosis is basically a life sentence but when we finally looked at that in large numbers, we found results that were starting to come aware of that that the diagnosis drops off for most individuals.
We’ve also learned, unfortunately, that most individuals without very focused treatment continue to struggle with their life functioning. We started to see some suggestions of recovery with targeted treatments. But we know so little about it — so little about the lives of individuals who are in recovery and identify themselves as being in recovery. The impressions that I’ve given — how common are those? Are there other things that didn’t enter into this conversation that are very crucial parts to the story — both in terms of people’s subjective experience also in terms of neuroscience?
We’re learning more about what does the brain look like for individuals with BPD when they’re experiencing their pathology, when they’re experiencing their suffering. But what do brains of individuals in recovery look like compared to those who never had borderline, what does it look like before and after treatment — people are starting to do that research but we really don’t know that yet.
So I’d really like science to advance these issues and inform us therapists.
Dr. Axlerod on what recovery looks like:
If we’re talking about individuals who are coming from a place of feeling out of control, being out of control in terms of their emotions, in terms of their reactions, really caught in misery… I think that recovery as individuals who have developed controls, who not only developed controls of their behavior and have been able to manage their moves but have also taken steps forward in their life so that they are seeing themselves in the process of building a life that they wish to live, that they’ve put things into their life that they would want to maintain. They’ve gone from a place where they could do that to a place where they are clearly starting to do that or have put together a life that they wish to continue to live.
One thing that has been my experience with such individuals who are in recovery from BPD is that they’ve developed insight into when they get experiences of being under stress, under unexpected stress, of mood episodes, difficulties with thoughts or urges about self-destructive behaviors, a thought that they should kill themselves, a thought that they should hurt themselves, or a really intense desire to hurt themselves — that they’ve developed insight as seeing this as an understandable reaction given that it is in their history.
Given that they used to cope that way and that they’re prepared to cope that way, without the panicking, without the fear of oh no, I have the thought of killing myself and that means my whole world is going to fall apart again and go back into self-destruction, I’ve seen individuals who can say, oh, I just had the thought I want to kill myself — something must be bothering me. There must be something going on.
And to look at things and take a step back and see what’s troubling them and maybe look to their supports, but to do so with confidence, that they’re still committed to living their life, still committed to going forward and that they will go forward. That the “bump” of something in their mood, thoughts or urge isn’t more than that — that it’s information that there’s something they need to pay attention to, but it’s not determining what’s going to happen next in their life. That they’re not going to unravel and I think that’s a critical period for individuals in recovery to develop mastery, that insight, and develop the sense of mastery that they’re life can go on and that the individual embraces it.
I’ve seen several individuals embrace the notion that they have interpersonal sensitivities, they have urges that may pop up, and that it’s worth living their life, and it’s worth taking care of themselves effectively when those kinds of things come up. Because they’re going through life and they want to keep living their life. I see that at this point as kind of a working definition or world examples of things that I associate with BPD recovery.