Original source: Rating Your Psychotherapist, a book by Robert Langs, M.D.

1. The Referral: I know of this therapist because...
2. The First Contact: This is how the first contact happened
3. The Setting: This is how my therapist's office is set up
4. The First Interaction: This is how my therapist handled the first interaction
5. The Fee: This is how my therapist handled/is handling the fee
6. The Schedule: This is how my therapist handled/is handling the schedule
7. Privacy, Confidentiality, and Anonymity: This is how my therapist handles the issues of privacy, confidentiality, and anonymity
8. The Therapist's Interventions: This is how my therapist intervenes
9. Terminating the Therapy: This is how my therapist handled/is handling termination issues

Please be advised that the "Rate Your Psychotherapist" test is only a guideline. I can not stress enough that each individual is different! You, and only you, know if your therapy is working/going to work for you. The Langes Guidelines are here only to encourage you to understand that YOU HAVE RIGHTS. And that it's ultimately YOU who decides who is best to give you the therapy you need.

Many patients feel obligated to stay with "this-or-that therapist." If you feel your therapist is the wrong therapist for you, you can change that. If you feel your therapist is great for you, it doesn't matter what any test says. Stay with your therapist and continue on your road to healing.

I hope this proves to be a helpful tool for you. It's designed to help you think carefully about your present therapist or, if you're looking for a therapist, use this as an aide in your search.

Read this letter I received from another professional before going on, and again, hear the words I just stated above.

"It is best to rate your psychotherapist from the first moment to the last. There can be no hard-and-fast rules; personal judgment will always come into play. As the ratings accumulate, keep a tally. High ratings support the work the therapist is doing, but they need to be understood in the context of the course of the therapy and how the treatment is going. Low ratings are cause for concern, but here, too, a perspective must be maintained. Consider the total picture of your life and combine that with the ratings of your psychotherapist, and use all available information for your assessment."

Reproduced from: Rating Your Psychotherapist, a book by Robert Langs, M.D.

TABLE 1: The Referral
Rate Your Therapist
I know of this therapist because:

Sound Answers

• My local Medical Society/Mental Health Association/professional organization recommended him/her.
• My family doctor recommended him/her.
• He/she came to see me for a consultation when I was in the hospital.
• A friend who's a psychiatrist/psychologist/social worker/mental health professional recommended him/her.
• My employer/principal/lawyer recommended I see him/her.

Questionable Answers

• My former/present therapist recommended him/her.
• He/she is the therapist I was assigned to in a group practice/clinic.
• He/she is at the clinic where my health plan requires me to go.
• I picked him/her out of the phone book.
• I pass his/her office on my way to work.

Unsound Answers: Reconsider Your Choice of Therapist

• I saw his/her name in a telephone book/on television/in the paper.
• He/she works in a different section of my office complex
• His/her office is in my apartment building.

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Dangerous Answers: Beware of This Therapist

• A coworker/social acquaintance/relative sees/used to see him/her and says he/she is good.
• I used to see him/her with my parents/children/spouse in family therapy and I liked him/her.
• My daughter/son goes to school with his/her daughter/son.
• I've heard him/her lecture and he/she sounds like a good therapist
• He/she is my minister, so I know him.
• I've read his/her books/seen him/her on television/heard him/her on the radio.
• His wife/her husband is one of my friends.
• I met him/her at a party and he/she gave me his/her card. I took a course from him/her and he/she seemed really insightful.
• I used to date him/her/I'm currently dating him/her, so he/she must know me pretty well.
• He/she is one of my father's/mother's colleagues.
• He/she is a coworker and seems bright and helpful.
• He/she is a friend/used to be a friend of the family.

Table 2: The First Contact
Rate Your Therapist
This is how the first contact happened:

Sound Answers

• I made the contact by telephone.
• The therapist answered the phone directly.
• The therapist had an answering machine/service and returned my call the same day.
• The contact was brief and to the point, handled professionally, and by the therapist alone.
• A definitive appointment was made - to occur within a few days of the call.
• The therapist gave me directions to his/her office.

Questionable-to-Unsound Answers: Reconsider Your Choice of Therapist

• Someone made the appointment for me (not an emergency situation).
• I met the therapist in person at a walk-in clinic or in a hospital emergency room.
• I called and left a message, but the therapist didn't get back to me for a day or so.
• The therapist was booked up - he/she couldn't see me for weeks.
• I made the appointment with a secretary.
• I had a long talk with the therapist when I called him/her - he/she asked lots of questions about my symptoms and history.
• I conveyed a sense of emergency, but the therapist didn't seem to take me seriously.
• I got off the phone and realized I didn't know how to get to the therapist's office.
• The therapist didn't seem to want to end the conversation, even though we had covered all the essential information.

Dangerous Answers: Beware of This Therapist

• Someone made the appointment for me so that I'd feel obliged to go.
• The therapist had his/her spouse call me back and make the appointment.
• The therapist didn't get back to me, and when I called again, I found out that he/she had forgotten.
• I told the therapist that it was an emergency, but he/she was completely insensitive to my situation and told me to make an appointment for later in the week.
• The therapist told me all about himself on the phone - where he/she went to school, what he/she believes about therapeutic technique, what his/her spouse does for a living, etc.
• Having ascertained my problems, the therapist prescribed medication over the phone.

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Table 3: The Setting
Rate Your Therapist
This is how my therapist's office is set up:

Sound Answers

• He/she maintains a private office in a professional building.
• There is a bathroom readily accessible from the waiting room.
• There is a door in the therapist's office that allows me to leave without having to go back through the waiting room.
• The furnishings are tasteful but not obtrusive.
• The windows have shades or blinds that are closed.
• The office is soundproof.

Questionable-to-Unsound Answers: Reconsider Your Choice of Therapist

• He/she maintains a home-office separate from his/her living quarters.
• He/she shares the waiting room with other therapists, so I'm usually not alone there.
• He/she has an office in a clinic.
• The only bathroom is just off the therapist's consultation room.
• I always meet the next patient in the waiting room on my way out.

Dangerous Answers: Beware of This Therapist

• He/she uses his/her living quarters as an office.
• When I go to my therapist's home-office, I'm aware of his/her family.
• My therapist's office isn't soundproofed; you can hear what's being said inside - particularly if someone is shouting or crying.

Table 4: The First Interaction
Rate Your Therapist
This is how my therapist handled the first interaction:

Sound Answers

• He/she seemed to be concerned and listening.
• He/she said very little - restricting comments to attempts to help me understand myself better.
• He/she answered no questions, but sought more exploration from me.
• He/she said nothing of a personal nature.
• Except for an initial and concluding handshake, there was no physical contact between us.
• In the second half of the session, the therapist briefly stated that he/she could help me and then proposed a set of ground rules for treatment.

Questionable-to-Unsound Answers: Reconsider Your Choice of Therapist

• He/she was angry.
• He/she was indifferent.
• He/she was seductive.
• He/she talked almost as much or more than I did.
• He/she asked a lot of questions, which broke my train of thought.
• He/she kept giving me his/her personal opinions and told me about his/her private life.
• He/she gave me specific advice on how to handle my problems.
• He/she asked me to lie down on the couch for the consultation hour.
• He/she tended toward nonsexual physical contact - such as giving my hand a reassuring pat when I was nervous and upset, etc.
• He/she didn't say anything about whether he/she could help me or what the ground rules of therapy would be.

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Dangerous Answers: Beware of This Therapist

• He/she was very demonstrative physically - hugging me, touching my arm or shoulder
• when talking to me, etc.
• He/she came on to me sexually.
• He/she was verbally/physically assaultive.
• He/she was downright unprofessional - very personal in his/her responses and
• self-revealing.
• He/she was exceedingly manipulative.

Table 5: The Fee
Rate Your Therapist
This is how my therapist handled/is handling the fee

Sound Answers

• He/she proposed a single, reasonable, fixed fee.
• He/she didn't barter or bargain with me.
• He/she holds me entirely responsible for the fee; I can't use a third-party payer.
• He/she won't let me build up a debt.
• He/she won't accept gifts or other forms of compensation beyond the agreed-upon fee.
• He/she has not changed the fee during the therapy.
• He/she holds me responsible for the fee for all scheduled sessions.

Questionable-to-Unsound Answers: Reconsider Your Choice of Therapist

• He/she let me decide what I wanted to pay.
• He/she gave me a fee range.
• He/she told me that he/she was charging more (or less) than his/her customary fee.
• He/she says that I don't have to pay the fee when I go on vacation, take business trips, get sick, attend a wedding or funerals, etc.
• He/she accepts third-party payment (from parents, an insurance company, a governmental agency, etc.).
• He/she gives me/accepts small gifts on rare occasions.
• He/she lets me build up a temporary debt when I'm having a hard time financially.
• He/she takes the fee in cash (and keeps no record).
• He/she asks to be paid in advance of the sessions.

Dangerous Answers: Beware of This Therapist

• He/she is willing to falsify a fee to an insurance company for me.
• He/she negotiated a barter arrangement with me, which bypasses taxation.
• He/she gives me expensive gifts and accepts them from me.
• He/she accepts financial tips/stock information from me.
• He/she traded me a low fee for cash payment.

Table 6: The Schedule
Rate Your Therapist
This is how my therapist handled/is handling the schedule:

Sound Answers

• He/she arranged a definite schedule for my therapy - day, time, frequency, and length - and these have not changed through the course of my therapy.
• At most, the schedule has changed because of a major change in my work/school schedule or life circumstances or a new and major professional commitment by the therapist.

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Questionable-to-Unsound Answers: Reconsider your Choice of Therapist

• There are minor and occasional shifts in the time and length of sessions; a rare emergency hour.
• There isn't really much of a fixed schedule.
• When I don't come, I don't have to pay, and I can have makeup sessions.
• As therapy was coming to an end, my therapist decided to reduce the frequency of my sessions - a sort of tapering-off strategy.
• He/she has lapses, but rarely: extending or shortening an hour, failing to be there for a scheduled session.

Dangerous Answers: Beware of This Therapist

• He/she repeatedly changes the time and/or day of the sessions.
• He/she often starts late because other patients stay past their scheduled times.
• He/she often lets me stay longer than my scheduled hour, particularly if there's no one else waiting to see him/her.
• He/she has asked me to shift my hour so he/she can see some other patient during my scheduled time.
• He/she has canceled sessions in order to vote, move into a new house, take his/her dog to the vet, etc.
• He/she keeps recommending that I see him/her more often than I want to.
• He/she often walks out with me and hangs around making small talk before the next patient comes in.

Table 7: Privacy, Confidentiality, and Anonymity
Rate Your Therapist
This is how my therapist handles the issues of privacy, confidentiality, and anonymity:

Sound Answers

• He/she is not deliberately self-revealing.
• Total privacy and complete confidentiality have prevailed throughout the therapy.
• When I ask my therapist about himself/herself, the response is an attitude of listening and exploration.
• He/she has not prescribed medication.
• He/she does not take notes and does not record the sessions.

Questionable-to Unsound Answers: Reconsider Your Choice of Therapist

• He/she, on rare occasions, has offered a personal opinion or alluded to his/her professional status.
• He/she is obligated to send specific reports to my employer.
• He/she has to provide nonspecific information to the agency that pays for my therapy.
• He/she occasionally offers opinions or information about himself/herself if I'm persistent enough.
• He/she prescribed medication when I was in a state of extreme emotional dysfunction.
• He/she does not usually make physical contact with me, but has done so on rare occasions, for example, when I was experiencing a sudden traumatic loss.
• He/she sometimes takes notes when I'm talking.

Dangerous Answers: Beware of this Therapist

• He/she is more like a friend than a therapist - telling me about his/her own life, introducing me to his/her spouse, offering me the use of his/her books/home/car, etc.
• He/she talks about my material in his/her books/lectures/classes.
• His/her secretary clearly knows a lot about what I've said in my sessions.
• He/she videotapes our sessions for use with his/her psychiatric residents.
• He/she spends so much time talking about himself/herself that I have to fight for my own therapeutic space.
• All I have to do is say I've been feeling depressed, and he/she will ask if I want medication.

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Table 8: The Therapist's Interventions
Rate Your Therapist
This is how my therapist intervenes:

Sound Answers

• He/she doesn't say anything most of the time; I do most of the talking.
• When he/she intervenes, it's almost always to explain the unconscious basis of my problem in light of my unconscious perception of something the therapist said or did.

Questionable-to-Unsound Answers: Reconsider Your Choice of Therapist

• He/she is sometimes silent for long periods of time, even though I have dreams that suggest the silence is inappropriate (dreams about people who don't understand, are insensitive, neglecting, etc.).
• He/she asks questions, repeats what I've said to clarify it, and confronts me sometimes on contradictions in what I've said.
• He/she asks questions, repeats what I've said to clarify it, and confronts me sometimes on contradictions in what I've said.
• He/she generally tells me what something I've said and asks me to say more about it.
• He/she occasionally picks up on something I've said and asks me to say more about it.
• He/she occasionally offers an empathic response, such as, "That must have been very painful for you," or "It sounds like you were pretty angry."
• He/she has occasional lapses in neutrality - sometimes gets quite angry with me/says something flirtatious/seems bored/falls asleep.

Dangerous Answers: Beware of This Therapist

• He/she is often silent for several sessions running, even though I've told him/her outright that I'm uncomfortable with it. In fact, I wind up spending a lot of those sessions talking about people who don't care about me or are afraid of a real relationship.
• He/she is constantly directing me to talk about particular issues, such as, "You haven't said anything about your mother for a while; how's that relationship going?" or "I'm interested in the fact that you were smiling when you mentioned being hurt. Why do you think you did that?"
• He/she is always telling me what I should be doing with my life, such as, "What are you afraid of? If I were you, I'd go for it."
• When I said that I resented his/her accepting phone calls during my sessions/keeping me waiting/taking notes, he/she said that other patients don't see things that way, and that I have a problem.
• He/she seems positively hostile to me -- alternately sarcastic and indifferent.
• He/she is seductive with me and seems hurt when I don't respond.

Table 9: Terminating the Therapy
Rate Your Therapist
This is how my therapist handled/is handling termination issues:

Sound Answers

• I introduced directly the possibility of ending therapy.
• My therapist interpreted my unconscious allusions to termination
• I felt a sense of new insight and deep understanding, and my symptoms had largely been resolved, so it seemed like the right time to terminate.
• I set a specific date for termination, and it remained unchanged.
• All the ground rules were maintained to the very last session - frequency, time, etc. Once therapy was over, I had no more contact with my therapist.
• The therapist maintained his/her analytic attitude to the very end.

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Questionable-to-Unsound Answers: Reconsider Your Choice of Therapist

• My therapist introduced the possibility of ending the therapy because my symptoms seemed to be alleviated.
• My therapist says we have to terminate because he/she is moving to another state/giving up clinical practice/taking another job.
• My therapist proposed we terminate therapy even though my symptoms are not entirely resolved.
• I think termination is indicated, but my therapist thinks we ought to continue, despite the fact that I feel much better.
• As the termination date got closer, my therapist said we didn't need to see each other as often.
• Toward the end of therapy, my therapist began to tell me more about himself/herself and treat me like a colleague.
• I set a termination date, but we decided to move it up/back.
• My therapist arranged for a series of follow-up visits just to make sure I'm really okay.

Dangerous Answers: Beware of This Therapist

• We decided to end the therapy even though my symptoms hadn't changed very much.
• My therapist continued the therapy long after my symptoms were gone.
• My therapist told me very abruptly that we would have to terminate and never explained why.
• I decided somewhat impulsively to stop going to therapy, and my therapist simply accepted my decision without exploration.
• I decided to stop going to therapy, but my therapist insisted that I still needed help/wrote to my parole officer, saying that I shouldn't quit yet/told me that I'd be sorry.
• My therapist stopped seeing me so that we could date each other.
• When we knew therapy was ending, sessions got very informal - we'd see each other over breakfast or walk in the park, trade favorite books, etc.
• As termination got closer, my therapist stopped interpreting and began to give me advice on how to handle my life once therapy was over.
• After we stopped seeing each other as therapist and patient, we became friends.
• We made arrangements to be in touch with each other professionally after therapy was over.

Please be advised that the "Rate Your Psychotherapist" test is only a guideline. I can not stress enough that each individual is different! You, and only you, know if your therapy is working/going to work for you. The Langes Guidelines are here only to encourage you to understand that YOU HAVE RIGHTS. And that it's ultimately YOU who decides who is best to give you the therapy you need.

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next:   Some Known Triggers That Cause Switching

There will never be a moment in which you are not you. Some may try to hide their existence away, pretending they are someone they're not, but who is this act for? You know the ultimate truth; there is no hiding from yourself. The difficulty of it lies in our societies' ability to create perfect illusions.

A young woman named Anna Westin wrote these words in her diary in November 1, contemplating the toll taken by a battle with anorexia that began when she was 17. Anna lost her battle a few months later, after taking a fatal overdose of painkillers. She was 21 years old.

Eating disorders are a growing problem affecting millions of people in the United States, most of them young women. This hidden epidemic, which has gained widespread public attention only in recent years, can be lethal. Yet sufferers often don't look as gravely ill as they truly are, and hide their illness behind a "perfect illusion" of normalcy.

The PBS documentary, Perfect Illusions: Disorders and the Family, hosted by Lauren Hutton, is unique in its focus on the role of the family in the evolution and treatment of, and eating disorders recovery.

What are the risk factors? How do you identify early warning signs of eating disorders? Where can families turn during the treatment and recovery process? These questions and more are addressed in this documentary about a challenging situation faced by more people in our society than we might think.

In Perfect Illusions, you will meet 16-year-old Suni, who is in the early stages of what may be a long and difficult fight with bulimia; 26-year-old Marya, who chronicled her 15-year struggle with anorexia and bulimia in the book Wasted; and 20-year-old Annie, who became bulimic during a bout with clinical depression in high school. Thoughtful entries from the diary of Anna tell of her ordeal.

The young women's parents tell about their desperate efforts to help their daughters, and of the fear, confusion and frustration they've faced trying to deal with a problem that has no single cause. Perfect Illusions includes interviews with specialists in the treatment for anorexia and treatment for bulimia, and visits a support group for the parents of those suffering from eating disorders.

Suni, Marya, and Annie talk candidly about their experiences, recalling how their eating disorders began in response to pressures and stresses in their lives. The women describe how eating disorders forced them into a life of secrecy and evasion.

Annie's parents didn't find out about her bulimia for four years, until their daughter was a sophomore at college 2,000 miles from home, and a sorority sister called to alert them to the problem. Marya started making herself throw up when she was nine years old, but her parents didn't learn about it until they visited her in boarding school and found their 14-year-old daughter "skeletally thin."

Perfect Illusions is an unprecedented exploration of the role family issues and societal pressures can play in eating disorders. Annie describes the obligation she felt to live up to what she perceived as the expectations of her family: "There were a lot of 'shoulds' in my life. 'I should do this, and in order to be a good person, I need to do this. It was... my pattern of constantly feeling like I needed to live up to something."

The documentary also examines the traumatic impact of anorexia and bulimia, on the sufferers' loved ones. Marya's parents talk about the agonizing day they placed their daughter in an institution for teens with mental and emotional problems. Families not only deal with the deadly nature of the disease and the threat to their children's lives, but also with the guilt of real and perceived responsibility.

Anna's best friend, who also fought anorexia, remembers her shock when she visited Anna in the hospital: "My heart is just totally broken, because she just didn't look at all like herself or how I had ever remembered her... it just crushed me."

The documentary is an exploration of the role that family issues play in eating disorders and the pressures exerted on these young women to live up to what they perceive as the high expectations of their family and society. It also examines the traumatic impact of anorexia, bulimia and binge eating on the sufferers' loved ones. Families deal not only with the deadly nature of the disease and the threat to their children's lives, but also with the guilt of perceived responsibility.

The treatment of anorexia and bulimia can also exact a high financial cost. In most states, insurance companies deny coverage for long-term in-patient care for eating disorders. Often parents must cover the costs themselves. Anna's parents believed their insurance company's denial of treatment contributed to Anna's death. They helped spearhead a Minnesota lawsuit that resulted in a landmark settlement against the company. They used their one million dollar award to establish a residential treatment center for eating disorders.

While recovery can be a challenge, treatment for eating disorders is completely effective in many cases. For some, the road is complicated and hard. Recovery takes more than will power. There can be a complex interaction between family, brain chemistry, personality, genetics, and individual history. New research on genetic and biochemical factors may shed light on causes and treatment in the future. Research is ongoing in many areas and the outcome offers increased hope for sufferers and their loved one.

Watch video clips:

• The Deepest Secret
  In a society that promotes the image of being thin, it is difficult for these women to reconcile...
• I Really Was That Crazy... It Wasn't A Joke Anymore
  I realized they were talking about putting me in a mental institution for good...
• I Wanted To Be Perfect
  It seemed to me children ought to be adults...
• Family Therapy
  Annie is now in individual therapy; this has become a source of conflict...
• After Family Therapy
  After two days of family therapy, Saras is looking at herself, and her family relationships, differently...
• In Most States, Insurance Companies Deny Coverage
• The insurance company, who had never talked to Anna, had never seen her, didn't know anything about her...

Perfect Illusions: Eating Disorders and the Family is available on VHS and DVD at Channel9Store.com or by calling 1.800.937.5387

©2003 KCTS Television

next: Appearances Fail to Paint Whole Picture
~ eating disorders library
~ all articles on eating disorders

No Secrets, No Lies: How Black Families Can Heal From Sexual Abuse by author and journalist Robin D. Stone is a resource guide for families seeking to understand, prevent and overcome childhood sexual abuse and its devastating impact on adult survivors.

Below, Stone shares 10 facts about sex abuse in the African-American community:

• It's more common than you think: In surveys of adults, 1 in 4 women and 1 in 6 men report that they were sexually abused as a child.

• It's a black thing, too: Many African Americans think that child sexual abuse is more typical among white people. Statistics show that blacks are sexually victimized in childhood at about the same rates as whites.

• Near and present danger: Two-thirds of all victims of sexual assault reported to the police were under 18. In nearly 95 percent of the cases, the offender was a family member or acquaintance.

• 

  Rich or poor: Poverty, which contributes to violence in many communities, is not seen as a risk factor for child sexual abuse. Abuse is more likely to be reported among low-income families, but is virtually undetected in families whose money or status shield them from authorities.

• Race matters: African-American women are less likely than white women to involve police in cases of child sexual abuse. Fears about betraying the family by turning abusers into "the system" and distrust of institutions and authorities often lead blacks to remain silent about "family business."

• Boys are also abused: About 14 percent of all young victims of sexual assault are male, according to police reports. Twenty percent of sexual abuse of boys is committed by women. Among African Americans, homophobia perpetuates the denial of sexual abuse of boys.

• Cause and effect: Black women report being more severely abused with greater force. They also report "more upset, greater long-term effects and more negative life experiences" from sexual abuse than white women. Among the effects: post-traumatic stress disorder, depression, anxiety, eating disorders, substance abuse (drug abuse), self-mutilation and more.

• Young and troubled: Adolescents commit 23 percent of all sex offenses. Experts say young abusers are more responsive to treatment than adults.

• Prolific predators: Child sex offenders tend to victimize more often than other sexual offenders. Seventy percent of child sex offenders had between one and nine victims; 23 percent between 10 and 40 victims.

• Quiet as it's kept: Child sexual abusers operate in silence and isolation, the tools they use to target and control their prey. Few tend to be violent, which makes them difficult to catch and thwart.

Click the link to purchase the book No Secrets, No Lies: How Black Families Can Heal From Sexual Abuse by author, journalist and abuse survivor Robin Stone. Robin D. Stone is a former executive with Essence Magazine, Boston Globe and New York Times. In this book, Stone has covered every possible aspect and cause of sexual abuse. She accurately discusses the reasons and terrifying consequences that are plaguing numerous African-American families that have suffered from sexual assault. The powerful resource guide seeks to assist families to thoroughly understand, prevent and overcome the devastating impact of sexual abuse on adult survivors.

next: Black Undergraduate And White Undergraduate Eating Disorders And Related Attitudes
~ eating disorders library
~ all articles on eating disorders

Online Conference Transcript

Leland Heller, M.D. is a family practice doctor who specializes in psychiatric illnesses. He is a Borderline Personality Disorder treatment expert and author of the books, "Life on the Border: Understanding and Recovering from the Borderline Personality Disorder" and "Biological Unhappiness".

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

BEGINNING

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. I hope everyone's day has gone well. Our conference tonight is on "Diagnosing Borderline Personality Disorder (BPD) and Finding a Treatment That Works". Our guest is Leland Heller, M.D. His "Biological Unhappiness" site is located here at HealthyPlace.com. Dr. Heller is a family practice doctor. His office is in Florida.

Although he is a family practice doctor, during his residency Dr. Heller specialized in psychiatric illnesses and later became very interested in Borderline Personality Disorder. He has treated over 3,000 patients with BPD and has run a BPD support group for nearly 4 years. Dr. Heller has also authored two books: "Life on the Border: Understanding and Recovering from the Borderline Personality Disorder" and "Biological Unhappiness".

Good Evening Dr. Heller and welcome to HealthyPlace.com. Thank you for agreeing to be our guest. Because people in the audience may have different levels of understanding, please define Borderline Personality Disorder and it's effects on those who suffer from it.

Dr Heller: Good evening, It's great to be here. I have a way of explaining the Borderline Personality Disorder in layman's terms that might be useful. It's how I explain it to patients and their families.

Imagine you had a pet dog and it runs into the street and by accident, it's hit by a car. The dog's leg is broken and it limps off into an alley to lick its wounds. A friend of yours sees the dog and comes over to help. The dog is now feeling trapped and cornered - a "wounded animal" - and misinterprets the friend's attempts to help. The dog snaps at the friend's hand who is trying to help. The BPD (Borderline Personality Disorder) is a malfunction in the brain's trapped or "cornered" animal area. Under stress, a seizure develops in that area. That's why under stress while raging, a borderline will say to him or herself: "Why am I doing this" - yet be unable to stop it. It's a seizure - nerve cells firing inappropriately and out of control.

David: And the cause of Borderline Personality Disorder?

Dr Heller: The BPD has many causes including head trauma and brain infections, but it appears that emotional hurts literally damage the brain. Most likely the brain's support cells - the 90% of brain cells called "glial cells" - are damaged by traumas, causing the person to overreact to stress once puberty strikes. During puberty the brain's limbic system goes into "overdrive" and adolescents are at their highest risk of seizures in their lifetime. "Sticks and stones may break my bones...but names cause brain damage." So does incest, abuse, severe trauma, head injuries, attention deficit disorder, and other causes.

David: From my understanding, one of the biggest difficulties facing individuals who have BPD is maintaining stable relationships. This is a great cause of consternation for those people who are on the other side of the relationship. What causes this?

Dr Heller: There are a number of problems. The three most significant are 1) inappropriate mood swings; 2) misinterpretation of motives; 3) remembering those misinterpreted motives as real. Oftentimes self-fulfilling prophecies occur, and self-hate eventually leads to a significant other coming to the same conclusion - that the individual isn't worth being with.

David: I have received a few requests for the official criteria -- the DSM criteria for Borderline Personality Disorder. Here they are:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistent unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress related paranoia or severe dissociative symptoms

When a person comes into your office, Dr. Heller, are there any tests you do to determine if the person is BPD?

Dr Heller: I go over the DSM criteria. There are no blood tests, physical examination findings, or imaging studies that can give the information.

David: Here's an audience question:

CrossEyed Rottweiler: Are there neurological examinations that can support your theory of BPD?

Dr Heller: This is something I emphasize - no one "is" BPD, they have BPD. No more than someone is a bad gallbladder.

There are neurological soft signs. There can be short term memory impairment, visual findings - but these are specialized and are not specific to the BPD. In other words, it won't make a difference. The BPD is a potentially life-destroying illness that must be treated even without "proof." This is no different than someone going to the emergency room with crushing chest pain, shortness of breath, left arm numb, breaking out in a sweat and vomiting. It's presumed to be a heart attack first, and we go from there.

BarbNY: Why are some people affected by these "emotional hurts" and others are not.

Dr Heller: It's an excellent question. Virtually all of us are affected by the hurts. Some of us have more severe hurts, or less of a support system, or a genetic predisposition. It does depend upon the individual.

savanah: DSM is a way of labeling and is not a diagnosis. What can a person do to get a proper diagnosis?

Dr Heller: While any diagnosis can be used as a way of labeling or hurting someone, the BPD is a very real disorder that affects many, many people. I've not been a part of the diagnosis establishing, but my experience has made it clear it's very, very real.

David: To follow-up on Savanah's question though, people go to their doctor or psychiatrist hoping they are doing the right thing. How do you find the right doctor to treat BPD and secondly what should a good doctor be doing to determine the BPD diagnosis?

Dr Heller: A very difficult problem. I got involved as a family physician because the psychiatrists refused to take care of my suicidal borderlines. I literally had patients get on their hands and knees begging me to write my first book. That's how I got involved. I found medications that were working, I looked at the literature - and it confirmed these medication choices. There are no hard and fast rules. There are many, many physicians who really believe in what they do and in helping people as their highest priority. Sometimes they literally have to be interviewed by the patient. Finding someone who is open-minded and willing to look at the literature is crucial.

The information is there. Prejudice, misinformation, old information, and blaming patients for their problems get in the way. I get calls and correspondence from physicians all over the world who have used these medication combinations and retraining methods and also found them successful. The data is there, but with 1600 articles published daily it's hard for physicians to keep up on everything. The person responsible for your health is you, and sometimes you have to ask questions.

janet: Would you please tell us more about the self-hate characteristic and how that damages the BPD or his/her relationships?

Dr Heller: Much of it comes from self-destructive behaviors that are used to stop the horrible pain of dysphoria; anxiety, rage, depression and despair. When an individual behaves out-of-control, in a manner that's inconsistent with their beliefs or normal choices, terrible self-hate develops. Additionally, many individuals had low self-esteem and related problems since childhood and are in an environment that causes self-hate to flourish.

crazy32810: How is self-injury related to BPD?

Dr Heller: We all injure ourselves to stop noxious neurological sensations. Interestingly we do it in a linear manner, ripping the skin. A common noxious neurological sensation is the toxins released with an insect bite. BPD dysphoria is about as bad as it gets. The pain is horrible. Many individuals have broken major bones and declared the pain of the fracture was nowhere as severe as dysphoria. When an individual with the BPD discovers that self-mutilation, or other techniques of self-injury, work to temporarily stop the pain of dysphoria - they'll do what it takes to stop it. This is no different than the individual with a fracture wants pain medication. I broke my shoulder last December and I tried to deal with it without taking narcotics. I was foolish and wrong. The pain was so bad it needed to be treated medically. Once individuals with the BPD have their chronic symptoms stabilized, and have safe medication options that work for dysphoria, the self-destructive patterns are no longer needed to stop their pain.

David: I want to move onto the treatment of Borderline Personality Disorder. How are the treatments selected and what is available today?

Dr Heller: There are a number of treatment approaches. I agree completely with Dr. Karousi from 1991 where the use of serotonergic medications like Prozac, mood stabilizers like Tegretol, and low-dose neuroleptics like Haldol for transient psychosis can work.

My technique is to use the "screening test" that's available at my website here at HealthyPlace.com and look for the most common diagnoses. I also do the "Zung" depression index to see how depressed they are. I also do the DSM IV criteria for the Borderline Personality Disorder.

Once the diagnosis is established, I generally begin an SSRI - usually Prozac, adding Tegretol a week later. For some reason, it takes a week on Prozac for Tegretol to really work well. Some patients need Tegretol for a while, others just as needed.

I'll then treat the other diagnoses - the most common being the generalized anxiety disorder, attention deficit disorder, obsessive-compulsive problems, etc. It's extremely unusual for the BPD to exist by itself.

David: Dr. Heller, what role does therapy play in the treatment of Borderline Personality Disorder, and is it necessary?

Dr Heller: There are articles in the BPD section on the medications, the dysphoria instruction sheet I use for my patients, the literature and lots of other useful information sources. Therapy is extremely important for treating BPD. However, it rarely works well until the medications are correct. Borderlines have lots to learn regarding social skills, trying to determine which memories are real and which were incorrectly interpreted during psychosis, learning self-esteem, etc.

David: Here are some audience questions regarding treatment:

TheDreamer: Why is Tegretol used most out of all the mood stabilizers for BPD? Is seeing images and hearing commanding voices a part of BPD? Is 2mg of Risperdal high enough dose to rid these symptoms?

Dr Heller: Tegretol works the best. It's been around a long time, so we know a lot about it. Dr. Cowdry at NIMH did studies published in 1986 and 1988 in the Green Journal that showed tegretol worked to reduce behavioral dyscontrol. This was in a double-blinded cross over study. I use it the most for one simple reason - it works! ...and it works well!

Hallucinations can be a part of the BPD psychosis experience, but it's very uncommon. Temporal lobe seizure symptoms such as deja vu, unreality and seeing things through someone else's eyes are more common.

When Risperdal is needed, 3mg is the usual dose in my experience. It doesn't work well when used every day - it's better as a "control/alt/delete" medication to reboot the limbic system when it's stressed out.

summertime: My doctor won't push Prozac dose over 60mg/day because it is max in Britain. What else could I try? I'm also on Tegretol 200mg twice daily and Haloperidol as required.

Dr Heller: About 10% of patients need 80mg, and a few need higher. Dr. Markovitz and others are prescribing very high doses of it and other SSRI's. Prozac will be generic shortly, which should simplify the process. The dose of Tegretol doesn't matter - what does matter is the blood level. That needs to be in the upper half to third of normal. Haloperidol, as needed, is sensational. Just as crucial for treating the BPD is the other diagnosis, such as the General Anxiety Disorder, ADD (Attention Deficit Disorder), etc. Treating the Borderline Personality Disorder) alone rarely does the whole job.

Irene: How do you get help for a teenager who ABSOLUTELY refuses to get help and will NOT cooperate with a therapist?

Dr Heller: Another tough problem. After age 18, there's nothing you can do. Before 18, you're still the boss, even though the adolescent may believe otherwise. Worst case, the teen may need hospitalization. Once hospitalized, medications will be administered. Almost every teenager I've dealt with is willing to try if you present the disorder to them in a clinical and easy to diagnose manner. It's crucial to make sure they understand they neither caused their disorder nor chose it. Optimism about it's treatment is important as well. No matter how angry the individual with BPD is, they are still in pain and want the pain to stop. That "wounded" animal response is simply kicking in, and likely having a seizure. These seizures can be chronic as well. I tell my patients that I don't want them to believe me based on my words, because talk is cheap. I hope what I have said makes enough sense that they'll try the medication and see if I told the truth or not. I want results to speak for themselves.

David: For the audience, I'd be interested in knowing what treatments have worked for you.

Here are some audience comments on what has worked treatment-wise for you:

Marci: I was on Tegratol for several years which helped, and I was even able to wean off of it until a robbery recently which precipitated BPD rearing its ugly head again, and now nothing seems to help.

savanah: After my therapist dumped me, I got educated and began recovery on my own. I believe that you are accountable for how you feel.

ssue32: I have been on Depakote for many years and it has helped a lot plus I have begun therapy on abuse issues I never wanted to explore

David: I'm also interested in knowing from those of you with Borderline Personality Disorder; what is the most difficult aspect of having it?

Ona1: I find that my extreme mood shifts and behavior are the worst for me. That, and the self-injury aspect.

Silent: Not knowing what is wrong with you, but the constant feeling of being alone, the thought of wanting to die, is so depressing.

ssue32: For me, it is the self-injury and also believing at any minute I will be abandoned.

savanah: the most difficult aspect is trying to get loved ones to understand what it feels like to be BPD. It's like explaining to someone who has never had cancer what it feels like. Not easy!

Marci: I think for me the most difficult aspect is the stigma attached to Borderline Personality Disorder, and the difficulty of finding a professional to help you.

Rednebsaf: Trying to believe I don't have it every time I hurt myself

Ona1: I have recently been diagnosed with BPD and the most difficult thing has been the extremes of my behavior. I fight with it constantly.

donna2: The most difficult aspect of having BPD is not having a passion for anything. I see people with hobbies and collections and I have no interest in anything. All I do is survive from day-to-day.

cypress: I have also been recently diagnosed. Its hard to know whether or not the diagnosis is correct.

susie: Have been diagnosed with DID but many don't believe it. They say that I may have BPD.

David: One of the things that some have trouble dealing with are the extremes in behavior. What is your suggestion for dealing with that?

Dr Heller: The extremes in behavior are medical problems. The individual misinterprets reality, and acts reasonably based on that misinterpretation. The most important aspect here is medication, particularly as needed. The therapist I work with the most - and ran 3 treatment programs with - became interested when she attended some family support groups I ran. The therapist was amazed at how, as needed, Haldol worked. The family members saw the results.

David: One of the other troubling aspects that audience members mentioned was what I would call "severe depression". The sense of hopelessness that things won't get any better and despair.

Dr Heller: Once the medications are even partially stabilized, that dysphoria based depression is usually gone in 3 hours, at most 24 hours. The sequencing of medications can be as important as the actual medications.

An interesting but true story. I have a patient who was sexually molested from age 4-16. She was finally doing well. On a Monday morning, she came into the office in the fetal position saying she wanted to die - because her ex-husband had just been arrested for sexually molesting their four year old daughter. I gave her 3mg of Risperdal and 400mg of Tegretol and asked her boyfriend to stay with her until she falls asleep - likely within three hours. When she woke up the next morning she came into the office and said "Gosh Doc, I can't believe how much better I feel." She was better able to cope with the bad news which I believe speaks to the benefits and effectiveness of some medications. I see cases like this every day. Some patients need higher doses, but these are the results I expect.

Some recent scientific studies confirm that the depression in BPD dysphoria is a different phenomenon than regular depression.

David: I want to make sure I ask this next question clearly. Some doctors have told BPD patients that BPD is incurable. That, yes, some "symptoms" can be dealt with, but a complete recovery is impossible. Is that true? And is that your experience in treating over 3,000 BPD patients?

Dr Heller: I think that expectation is the problem. The comorbidities are the key. Unless they also have character problems, borderlines can do extremely well.

Two former self-mutilators work for me. They have to learn to like and love themselves, to gain self-confidence, social skills, and how to succeed in relationships. It's a learnable skill.

If the individual wants to be successful more than they want what they're doing to be declared "correct," they can have success in every important area of life.

My goals are very high - I want success in every important area of life. When not treated in this way, the literature shows that some will have moderate work success and no success in relationships - and that success depends upon being brilliant, obsessive, rich and good looking!

I don't believe that success and happiness are reserved for the rich and gorgeous. I believe in mastering the principles of success - because by mastering them you'll have learned the principles of being successful in everything important - including relationships.

Three things are necessary for success: 1) diagnosing and comprehensively treating everything that's wrong; 2) have a formal plan for stress and dysphoria; and 3) retraining the brain.

David: Here are some audience questions:

BarbNY: Do you believe in giving mega doses of SSRI's?

Dr Heller: Not in general. Most borderlines do well on 20-40mg of Prozac - which I believe strongly is the best one. Some individuals do well with high doses, and sometimes they're clearly needed, but high doses are expensive and potentially risky. Inappropriate moodiness, chronic anger, lack of energy, and emptiness are to me the most significant signs that a higher dose should be tried. The change is often dramatic by the next day.

Luci: As prozac at 40mg a day did very little for me I have been switched to Venlafaxine. Is there any evidence that Venlafaxine can be used successfully in aiding treatment of BPD?

Dr Heller: Yes. Effexor - the brand name - has been shown to work. I've never seen anyone do great on it. The studies are with very high doses - in the 450-600mg dose range. Side-effects are usually a huge problem at these doses. Effexor has effects on different neurotransmitters as the dose is increased. High doses have anti-psychotic effects, and the long term safety has clearly not been established.

I greatly fear the chronic daily use of medications that block dopamine - as neuroleptics and the GI medication Reglan have caused tardive dyskinesia. The newer agents are better and safer, but still have risks.

David: Here are some audience comments about what's being said tonight, then more questions:

donna2: I don't want to be on medications. I have such a small reality base as it is I'm afraid I'll lose it altogether. I was on various medications for years and nothing helped anyway.

cypress: I've been on medications for 3 months and I still feel suicidal.

donna2: I agree about depression in BPD being different. I don't want to kill myself, I want to kill the bad things that are bothering me. I don't lie around.

mazey: I am in recovery in all different areas including self-injury. I'm very afraid that one day I will snap and the borderline stuff will consume me again.

Dr Heller: It's not just medications, but which medications, the doses, and the sequence. That penicillin didn't work for moodiness doesn't mean another medication won't work. The long-term data is so profound that the choice to avoid medications is a very dangerous and painful one. It's not a tragedy that one needs medication, it's a miracle that such safe and effective medications are available.

Rednebsaf: How do you feel about Dielectical Behavioral Therapy?

Dr Heller: How do I feel about Dialectical Behavioral Therapy in treating Borderline Personality Disorder? DBT is an excellent program, and I give Marsha Linehan tons of credit for developing a counseling approach that reduced suicide and self-mutilation attempts by half. It's difficult to replicate in the "real world" of managed care, limited funds, etc. Actually, Dr. Linehan's approach and mine are quite similar in a lot of ways. This is particularly true regarding validating what the individual is feeling, talking straight with them, making them aware of consequences even though the brain is leading them towards places they don't really want to go.

cypress: I was on Prozac 80, but have been cut back to 40, do you consider 80 a "mega dose"?

Dr Heller: No - it's within the FDA approved dose range. Mega doses would be above the FDA approved levels for dosing. But "mega" is an arbitrary term. I want success for my patients, and sometimes the economics and politics behind FDA recommendations must be bypassed.

David: A few more audience comments:

cypress: It's hard to deal with the stigma of having a mental illness.

Jocasta: Your focus is much on medication Dr. Heller, and true that must be treating for the biological disorder that lives along with BPD. But is it not true that once medications are even somewhat effective, intensive therapy dealing with interpersonal skills, and ways of dealing with BPD by practicing working at relationships, working on improving self-esteem, and getting to the nitty gritty part that being abused is not one's fault; this is all in the post medication treatment, which has helped me equally.

Dr Heller: Jocasta: absolutely - which is what I've written about at length in my books, my website, and in tonight's chat. It's the combination of medication, as needed medication, and retraining the brain that's needed.

Zppt2da: I have had unhealthy relationships that I feel they are all related to an issue back from childhood with father. I have opened up a wound of self mutilating form 8 years, I have read titles of cutting and self mutilating and why this happens (overwhelming), and I am finding it hard to find a therapist who will take me on. You are threatened with a contract of no self injury, I have taken Dielectical Behavioral Therapy (DBT), but I don't know where else to turn too for help.

David: Dr. Heller, Zppt2da makes a good point, and it follows on something you said tonight.

Dr Heller: To Zppt2da: The trauma may have been a trigger for your condition, but it doesn't have to rule your life. I don't use self-mutilation as a cause to punish someone. That individual is in pain and needs help.

David: You mentioned that many therapists and psychiatrists don't want to take on patients who are suicidal. Where does one go then to get the help they need?

Dr Heller: Why you are who you are now and how you got here is of minimal importance, compared with who you want to be and how you get there. And that also includes patients who self-injure. You literally have to search, you have to have the information in hand, and you have to ask questions. There's lots of material on line - particularly on my site - that can be of enormous help to patients - including those who self-injure. Be educated, and bring concise information in for the physician. Physicians who are open minded - including open minded skeptics - welcome the opportunity to know more and to help patients. This is particularly true when non-addicting medications aren't used. Family physicians prescribe most mental health medications in the US - and that's a good place to start. There is a suicide attempt per minute in the US - it's not just a topic for psychiatrists.

ssue32: I am on Depakote, Wellbutrin and Celexa in high doses. Are these good for treatment of BPD, and are there any risks in the higher doses?

Dr Heller: Depakote is the more dangerous of the group. High doses of SSRI's can cause "serotonin syndrome" - although usually only when combined with other medications such as tricyclic antidepressants. Depakote often works as well as Tegretol, just not as consistently. Wellbutrin is commonly used also - particularly as it's other brand name "Zyban" to help patients quit smoking. I don't prescribe it very often. I have some patients on Celexa, but most prefer Prozac in head to head combination.

Silent: When in treatment, how long should it take for a person to find relief, or some relief, or does it never happen?

Dr Heller: I haven't had an individual fail to have a significant response in years - particularly when all the diagnoses are made. An individual with the BPD should be dramatically better within 7 days or something else significant is going on.

David: It is getting late. I want to thank Dr. Heller for being our guest tonight and sharing his knowledge and expertise with us. I also want to thank everyone in the audience for coming and participating. I especially like getting the audience involved because we can learn from each other too.

Dr Heller: It's been my pleasure, and I hope I've been of help to you.

David: Here's the link to the HealthyPlace.com Personality Disorders Community. I encourage to you sign up for the mail list so you can keep up with community events.

Don't forget to visit Dr. Heller's site Biological Unhappiness, and check his books "Life on the Border: Understanding and Recovering from the Borderline Personality Disorder" and "Biological Unhappiness".

Thank you, Dr. Heller.

Good night everyone.

Online Conference Transcript

Laura Paxton, counselor and author of "Borderline and Beyond: A Program of Recovery From Borderline Personality Disorder", is our guest. She discusses BPD symptoms and diagnosis, recovery from Borderline Personality Disorder, and her own experiences living with BPD for over 10 years.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Transforming Borderline Personality Disorder Into A Healing Experience." Our guest is Laura Paxton. Ms. Paxton has a Masters in Psychology and Counseling, and is author of "Borderline and Beyond: A Program of Recovery From Borderline Personality Disorder," which is a workbook she designed based on her own experiences of living with Borderline Personality Disorder (BPD).

Good evening Laura, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. To put what we are going to talk about tonight in context, could you start by sharing your experience with Borderline Personality Disorder? What did it stem from and what BPD symptoms did you experience?

Laura Paxton: I suffered from borderline personality disorder between the ages of 15 and 26. In my case, the disorder manifested as a major disturbance in mood, identity and relationships. Learning to live with the disorder, healing from the wounds and responding to its challenges, has given me incredible strength and has given my life incredible meaning.

Borderline Personality Disorder has a variety of causes, from biological to environmental. In my case, a combination of factors played roles. Most importantly was the failure to bond with a caregiver, as well as childhood abuse. Through my healing process, I learned about trust.

David: And you are how old, now?

Laura Paxton: 32 in two weeks.

David: What was life like living with BPD?

Laura Paxton: Stormy, intense and crazy. It was a roller coaster. My personal experience consisted of eleven hospitalizations over that eleven year period. I self-mutilated at different times and made a serious suicide attempt. I couldn't maintain a non-abusive relationship and I lived literally in hell. All of that time, I struggled to function as a professional and my ability to function unraveled until the healing process began.

David: Some professionals in the medical and psychological community believe that you can control some of the symptoms of Borderline Personality Disorder, but you can never get over it; completely recover. What do you think about that?

Laura Paxton: I know for a fact, based on my personal experience, that that is not true. I believe that since, in my case, I am living a happy, contented life (and without drugs for the past nine months) that more people could recover as I have. I have also worked with clients who are taking back control of their lives and learning to live symptom-free. So, I believe full recovery is possible.

David: I'm wondering if you are the exception to the rule when it comes to recovery, or are you of the belief that everyone with Borderline Personality Disorder has an equal chance of recovery?

Laura Paxton: I don't think there is anything special about me. I have seen recovery in the clients I work with when they begin to accept responsibility for their recovery and practice coping skills daily.

David: We have a few audience questions that I want to get to, then we'll continue with our conversation:

TS: Is Borderline Personality Disorder (BPD) a biochemical disorder or does it stem from trauma, or both?

Laura Paxton: I believe that both are true. Exposure to severe trauma often causes complete biochemical changes. Some cases of BPD have been reported in people with no abuse history, or who have suffered physical trauma only.

weaverwoman: I have both borderline personality disorder and multiple personality disorder. Have you run into this dual diagnosis before?

Laura Paxton: Sometimes these disorders are diagnosed simultaneously.

gracee124: Laura mentioned she has been "without drugs for the past nine months." What kind of drugs? Legal or illegal?

Laura Paxton: I have not taken any psychiatric drugs for nine months. Prior to that, I took Zoloft for about four years, Prozac before that, and Effexor before that.

ELIMAE: When Borderline Personality Disorder runs in your family, how do you know if you have it? I am having the same trouble as my sister, who has been diagnosed with BPD.

Laura Paxton: You need to consult with a mental health professional to receive a reliable diagnosis of BPD. If you are experiencing intense emotional experiences and instability in relationships, self-image and career, then you need to seek the counsel of a mental health professional.

David: Here is the diagnostic criteria for Borderline Personality Disorder.

Laura, I want to address the treatment for Borderline Personality Disorder. What is available today and considered the "first-line" treatment?

Laura Paxton: The most frequently recommended treatment for Borderline Personality Disorder is dialectical behavior therapy (DBT). Some patients have had positive results with Self Psychology. My program, Borderline and Beyond, integrates both approaches as well as some innovations that arose from my own recovery experiences.

David: So everyone knows what you're referring to, can you briefly describe what Dialectical Behavior Therapy (DBT) and Self Psychology are?

Laura Paxton: DBT is a program that focuses very heavily on the development of coping skills and practicing them in and out of a group setting. Self-Psychology deals with healing deficits in psychological development through forming a bond between therapist and patient. That is just a brief synopsis of two very broad approaches.

David: Considering that many who have BPD are suffering from abuse, coping with depression, self-injury, and other disorders, I imagine therapy is very complex and takes some time to reach a point where you notice real improvement.

Laura Paxton: Yes. Recovery is a long and complex process for most people. Generally, great improvement is not seen in the first year. However, there are exceptions. I think the most important factor is the willingness for the individual to take responsibility for her own recovery, to stay committed to that goal and to stick with recovery even when it feels too hard to continue.

David: Here are some more audience questions:

Sweetgirl01: Since biochemical changes occur in people who have experienced severe trauma, does it mean that it will take a lifetime of medication in order to correct that imbalance?

Laura Paxton: I used to believe this was true, and I took medications for a total of six years, thinking I would never be free of them. In my case, I don't need the medications anymore. I counsel everyone to talk to a medical doctor before making a decision to go off medications. They are essential for some people at some critical periods of recovery.

Baziust: Hello, I'm a "Major Object"/Victim. (Mother of a 26 year old 200 lb. BPD son). My husband and I were the victims of BPD rage and dysphoria from our son. When the patient's denial is working against us, are we supposed to just take it and remain victims ?

Laura Paxton: No. Absolutely not. Your role is to set firm, consistent limits but not to react with anger to his anger. People with Borderline Personality Disorder need structure and limit-setting and you should not live in fear of your son. Part of the acting out in dysphoria motivation is to see if you will still love and support him through the rage, but that doesn't mean you should tolerate abusive behavior.

Baziust: Then we handled it well yesterday. When he began to rage at us and abuse us with foul language, both dad and I were firm and said, time out!!! Go take a walk around the block. We insisted and he went. When he came back, he was a different person. I went down and gave him a hug. He seemed to appreciate that.

Laura Paxton: People suffering from BPD can be very dramatic and hurtful toward those closest to them. Baziust, it does sound like you handled the situation well with loving limit setting.

gracee124: The professionals have not been able to convince my daughter that medications will help, along with therapy for Borderline Personality Disorder. Can you suggest a way that will help to convince her? She is 17.

Laura Paxton: You may not be able to convince her they will help, but you might be able to help her to open up to giving them a try, if she is in enough pain to take the risk. You might also try letting her talk to someone else who is successfully taking medications.

David: I have a few audience comments on what's been said so far tonight that I'd like to post, then we'll continue with the questions:

TS: I can relate to being a victim to a son. We had to hold him accountable in court and finally the court could not help as they were afraid to send him anywhere. He continued to manipulate and threaten suicide every time the court ordered him into a juvenile setting. This was even with a psychiatrist's opinion to make him accountable after three visits to the hospital for treatment. We were all victims and now he went to his Dad's and then to a girlfriend's at age 16.

SuzieQ: In this JEALOUS insecure frame of mind, I become a hermit and antisocial to PROTECT myself from these feelings of jealousy and fear of being hurt.

Emma18: I was diagnosed with Borderline Personality Disorder about 3 years ago, when I was 15 and in the hospital for an eating disorder, suicide attempt, and self mutilation. I have read many things about borderline personalities to try to understand the disease but I still am so confused about what it actually is and what causes it and how I can help myself.

deeny: I think the chances of overcoming BPD problems depend on the relationship the sufferer is in or if they're in one. One of my main coping skills to counteract self cutting is to write, write, write!

Laura Paxton: Emma18 and deeny, yes, writing is an excellent coping skill. So is artwork. One of the key ways to work with this disorder is to channel the destructive urges into a creative direction. Also, deeny, a supportive social network goes a long way in the healing process.

Emma18, also the most important thing to remember is to learn to develop self-love and compassion for yourself to use as medicine in healing your wounds.

David: Here's the link to the HealthyPlace.com Personality Disorders Community. You can click on this link, sign up for the mail list at the top of the page so you can keep up with events like this.

We have an excellent site that deals with Borderline Personality Disorder: "Life on the Border."

Here's another audience question:

Skier4444: I have bought your book. Is it possible to use the workbook and get better without the help of a therapist?

Laura Paxton: I have received many letters from people who have stated they made a noticeable improvement in their recovery using the workbook alone. I usually suggest that my workbook be used in tandem with therapy or a support group, but it can be used as a stand-alone program as well.

Mensch: What do you think of the skills in DBT?

Laura Paxton: Many of them are critical skills to learn, such as emotional modulation and self-comforting. These skills are also stressed in my program. They require consistent daily effort and commitment to make them work. The core of all of the coping skills is developing a deep-rooted love for self and willingness to take responsibility for recovery rather than blaming self and others.

species55: I have been recovering for 7 years from PTSD (Post-Traumatic Stress Disorder), with dramatic biochemical changes in the brain along with attachment issues resulting from severe trauma by others. This has resulted in difficulties with trust. How were you able to overcome this hurdle?

Laura Paxton: One of the most important things I have learned is that the only person you ever really trust is yourself. You learn to trust yourself to set limits for you and protect you from harm, so that you can learn who is safe to open up to, but you never really trust another human being. I believe we only learn to trust ourselves. We can learn to do this by taking risks in opening up to safe people, but it has to start with discovering Self. I used to believe you could only find a sense of Self through learning to bond with another. Now, I believe that these two things are not mutually exclusive. I think that in the process of learning to trust ourselves, we learn to trust others and vice-versa.

ELIMAE: Is severe attention seeking a part of this disease?

Laura Paxton: Yes, for many people it is. Borderlines are experts at going to any lengths to get their unmet needs from childhood met, even if this paradoxically results in driving people further away. This is one of the most frustrating parts of the disorder for family and professionals.

Cheryle: How do I get over the feeling that I need to have someone in my life or I am no good?

Laura Paxton: Begin to affirm yourself, giving yourself positive messages even if you don't believe them right away. Also, spend time with yourself focusing on developing a loving relationship with yourself. Spend quiet time breathing deeply and focusing on developing love and compassion for your shortcomings. Love has to come from you. You will never be satisfied if you keep trying to find it outside of yourself. The good news is that if you try long enough to develop self-love, you will develop it.

SuicideGIRL: I have fantasies of cutting myself, but never have. Do you think I will in the future?

Laura Paxton: Only if you believe you will. I suggest consciously putting images in your mind of nurturing and loving yourself instead. If you continue to scare yourself with these images, you may feel compelled to act on them. The choice is always yours. Choose self-love.

mom12989: I personally have had so many traumas in my life, and multiple medical issues as well as mental illnesses. I have been a bulimic, for example, for 15 years. Do you think it is really possible to get completely better?

Laura Paxton: Yes, I absolutely do. I was diagnosed with profound depression as a result of my Borderline Personality Disorder, and my BPD was considered a serious case. I suffered for eleven years. It takes a huge amount of commitment, positive thinking, and daily practice of coping skills to do it, but it is possible.

blondie_punk_girll: Does a person have to experience a bad childhood to be borderline?

Laura Paxton: No. There are cases of people who report no childhood abuse who have been diagnosed with BPD. This is more rare, but possible because Borderline Personality Disorder is complex and has multiple causes.

2sweet2say: I am a case manager, and I want to know the best way to defray an explosive situation and benefit the individual, not just defer the problem?

Laura Paxton: After rage has escalated to explosiveness, the individual needs a huge amount of reassurance that she will not be abandoned and that she can prevent further episodes. What is most critical is to positively teach affective containment within the parameters of what's possible. Too often, professionals react with contempt to an outburst and focus only on getting through the episode safely and do not use it properly as the healing opportunity it truly is.

TS: Is the cutting EVER just for ATTENTION? My son did that. He carved LOSER in his forearm.

Laura Paxton: I don't think anything is EVER just for attention. Attention is as important to a child as food or oxygen. People need to know they exist, that they are valued and loved. Cutting is a way of saying: "I don't value myself, do you?"

David: Here are some more audience comments on what's being said tonight:

deeny: Cutting for me HAS NEVER BEEN FOR ATTENTION.

Baziust: Blondie punk girl - My son had two wonderful parents. His PTSD in grade 4 was the result of how he interpreted a schoolyard bullying incident. Being extremely sensitive, he interpreted it as a life and death situation and ended up with full-blown PTSD. Untreated PTSD, no doubt, contributed to his BPD.

Laura Paxton: Baziust, I believe that, in many cases, all BPD is a chronic, serious form of PTSD.

deeny: Medications help some, but more or less just takes the edge off.

Cheryle: I am taking paxil for panic attacks and it works great for that, but it seems like ever since I have been on it I have been suicidal, self destructive and have no self-confidence.

gracee124: The therapist has not wanted my daughter to know of her diagnosis. Although she is 17, the therapist thinks she is too immature to understand the diagnosis.

Laura Paxton: Gracee124, it is not necessary to know what the diagnosis is in order to recover. There is so much stigma associated with Borderline Personality Disorder that sometimes it is better not to know.

Cheryle: I am suicidal, an alcoholic, and a pharmaceutical drug addict. Is this caused by the disease?

Laura Paxton: You would need to talk to your doctor about this, Cheryle. This could be serious and needs to be looked at. Impulsive, self-destructive behavior is often a part of BPD, but they do not always indicate BPD in themselves.

serenity33: I have already been through DBT, and I was wondering if your workbook would be an enhancement to the skills I have already learned.

Laura Paxton: Serenity33, I have been told that my book is a perfect complement to DBT training groups. My program focuses on helping you experiment and learn which coping skills work for you.

2thumbs: I want to stop burning myself, yet I'm afraid to let it go.

Laura Paxton: You can learn to use coping skills which will help you let go of the urge to hurt yourself.

David: Also 2thumbs, you might want to visit the HealthyPlace.com Self-Injury Community and click on the sites there and read the conference transcripts.

Thought I was kidding about visitor support for the hosted support groups here? :)

pia: Yes, two thumbs up for the hosts who do the support chat :). Extra plug for the hosts of support chats :) They have been a life saver, and I've learned more in these chats than I did in years of therapy. :)

David: I know it's getting late. Thank you, Laura, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people interacting with various sites.

I invite you to stay and chat in any of the other rooms on the site. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Thanks again, Laura.

Laura Paxton: Thank you very much. 

David: Good night, everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Paula McHugh is our guest speaker. She is a licensed therapist who has been working with Dissociative Identity Disorder (DID), Multiple Personality Disorder (MPD) clients for the last 10 years.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our conference tonight is on Dissociative Identity Disorder, Multiple Personality Disorder. We'll be discussing "Whether to Integrate Personalities or Not To Integrate" and other DID, MPD issues.

Our guest tonight is Paula McHugh. Ms. McHugh is a licensed therapist and member of the International Society for the Study of Dissociative Disorders. She has been working with Dissociative Identity Disorder (DID) clients for the last 10 years. She counsels about 4-6 clients a week. She has helped 2 clients totally integrate, which she says can take anywhere from 4-8 years of consistent therapy to accomplish.

Good Evening, Paula and welcome to HealthyPlace.com. We appreciate you being here tonight. I know our audience members have different levels of understanding, so briefly, can you define Dissociative Identity Disorder, DID? Then we'll get into deeper issues.

Paula McHugh: Hello everyone. Dissociative Identity Disorder is a continuum of the ability to back away from stress. It helps people get away from trauma and forget about it. This usually happens in childhood when there is intense abuse, for instance, childhood sexual abuse. The result is a kind of splintered personality, where there is amnesia between people of the same system.

David: Before we also get deeper into the subject, please tell us a bit more about your expertise and experience in working with DID clients.

Paula McHugh: I have worked in this field for 10 years. I learned from my clients and from the experts how to help someone open up communication in the system.

David: What is involved in doing therapy with a DID client?

Paula McHugh: I bumbled around a bit in the beginning because it's a very complex thing and people are hypersensitive to any kind of criticism or rejection because they have seen this too many times before. First, is trust and safety, getting to know each other, then comes communication with alter personalities, if they are ready.

David: And in the type of therapy you practice, what is the end goal?

Paula McHugh: The hardest thing for clients is remembering what happened to them. That is the first goal, and it takes a long time.

There is competition between alters, so it's not easy going for the client, and they have to go slow in the beginning. It's pretty hard getting used to the idea that you're not the only one in the house - so the speak. It kind of freaks people out at first - like someone's watching. They kind of knew it before but didn't want to know it, if you know what I mean.

They always felt different because people would tell them they were lying about what they did or didn't do. Very confusing things appeared that they knew didn't belong to them. Time gaps where they all of a sudden appear at the beach or somewhere when the last thing they remember was being in school months or weeks or days before. So at that point, clients know something's wrong - but they don't know what, and they feel ashamed - paranoid, etc.

David: I imagine it must be a pretty scary thing to discover that you have these alters, separate beings so to speak, inside of you. How do people adjust to that or don't they?

Paula McHugh: It takes time. Sometimes they remember things that fit with Multiple Personality Disorder, MPD, and other times they say I'm out of my mind. Of course, I just say - well maybe I am.

The goal in therapy with Dissociative Identity Disorder always changes according to the client's needs.

David: At the top of the conference, I mentioned that you successfully helped clients integrate their alters. From your standpoint, as a therapist, is that your end goal?

Paula McHugh: That used to be my goal before I learned to listen better to my clients. Some people know that they want to integrate, but most people don't want to even talk about it!

I have learned that people change in therapy, alters become more similar - less opposite or different. The increase in communication in the system helps them feel more "together" - like a family. That may be all they want, or it may be all they want for awhile or for years. If it works for them - great!

Integration is not a must - it's a choice. No one can be forced to integrate and, my oh my, don't ever try to force someone with DID to do anything. No one wants to be forced, and they had to put up with people forcing them and abusing them forever, and they're not going to put up with it anymore. I didn't even think I ever tried to control things until one of my clients pointed out subtle things. That's what I mean when I say, I learned.

---

David: Paula, here are a few audience questions:

imahoot: Do you feel that when someone is very much in the healing process, that they unconsciously begin the integration process?

Paula McHugh: Yes, I do think so. It just kind of happens because there's not so much need for protection and barriers and the amnesia is gone.

debb: Do you think people are ever 'cured' or do we dissociate for life.

Paula McHugh: Yes, people are cured. They will always be susceptible to stress, so they have to watch out when they feel stressed because they know how to split, and it can happen again.

But that's not the end of the world. You just deal with the new person until they're OK. They will probably decide you don't need their help anymore. Alters formed after total integration do not have the hold on their life the way alters who had been there for years did. They're just there to help for a while.

dendroaspis: How do you define "cured"?

Paula McHugh: Cured is total integration which remains stable for 3 years. It's all the alters together - into one being. No one is lost, they are just all there in a different way, they don't have to share time anymore, everyone is up front all the time but in an organized, calm way.

David: Is splitting a conscious act on the part of the individual or is it something that happens unconsciously?

Paula McHugh: Totally unconsciously. These are children, and they feel trapped, desperate, and terrified. Somehow, they tap into an ability in the brain to split away to be in the trees or asleep, while someone else takes over. It's not conscious and I think it's a survival skill.

The other options are to go crazy - or kill yourself. So it's better to let our unconscious take over.

David: Here's the next question Paula.

deli: Once the personalities come together, what's the next step?

Paula McHugh: A long step. It's getting used to the idea of being a singleton. Like there's only Pepsi in the icebox because no one else buys milk, so you have to remember to buy the milk. But people tell me they feel "right," they feel good, calmer, less afraid.

They also have to get used to being alone. That's kind of sad for them for a while in between feeling better.

danalyn: You say it takes 4-8 years for integration. How many hours a week of work is that?

Paula McHugh: I think it's necessary to have therapy twice a week - and room for crisis sessions in between. Sometimes a 2 hr session if memory work needs to be done. It's arduous - but DID people are persistent. They are also in a lot of pain and want some relief. They do feel relieved after they do memory work and the nightmares stop.

David: Here's an audience comment:

dendroaspis: I guess that if a poor person wants to integrate, they are out of luck. I'm having no luck even getting a doctor.

David: That can be pretty expensive. My guess is many people can't afford that, especially if they don't have insurance. What then?

Paula McHugh: It is expensive, but people seem to think it's so important to them, that they will give up just about anything to have their therapy.

whalevine: How will we know we are ready to integrate?

Paula McHugh: You will know because it will feel right and it won't be so scary. If you're wondering, it's probably not time. All the memory work has to be pretty much done or the integration just won't work.

insight: There is total amnesia with some people with multiple personality disorder. In my case, I am co-conscious in the background when an alter takes over. Do you work with many clients with co-consciousness DID?

Paula McHugh: Yes, I do. There are many faces and many forms to DID. They are all different and all similar. There is not just one right way.

Pam: How does one deal with very self-destructive alters and keep themselves safe?

Paula McHugh: Everyone has to work together to be as aware as possible when the alter is really down or depressed or hurt. Sometimes a protective place - a beautiful room - inside can feel safe for them. Most of all, I believe that alter needs to be heard in therapy. They need to get the worries out in the open, so they can dissipate. That takes a long time. So in the meantime, whatever you all can do to be aware of what he or she is doing -- will help.

David: I have a question. How does one explain to others who are important to them that they have Dissociative Identity Disorder; that there are alters inside of them?

Paula McHugh: Do you mean outside family or friends?

David: Yes, exactly, friends, family.

Paula McHugh: Gently --- and in a questioning tone, especially RESPECTFULLY like - "do you think it might be possible?", "what do you think happened when you didn't remember the weekend?" NOT judgmental or critical --- just soft and gentle.

Also, it's hard for family members because they are probably in denial too, but that's a whole other discussion.

---

David: I would imagine that would be one of the most difficult things for someone with DID to tell someone else and not appear "crazy." And on the other side, I'm trying to imagine being the recipient of the message, not knowing much about DID and hearing this. So I do understand what you are saying.

Paula McHugh: Yes, it's scary to come out because you can never tell ahead of time how people will react. Most people are curious and helpful but some are not. I wouldn't recommend telling your boss either. Lots of people want to know more. They want to help. Sometimes, they want to know too much, too many questions, and DID people begin to wonder do you like me only because I'm DID?

David: If you have a therapist, is it important to have the support of family and friends to work through the issues involved. For instance, in eating disorders recovery, the professionals stress the importance of a support system. What about with DID?

Paula McHugh: You're very lucky if you have family support because more often the family is in denial and even tends to blame the person or say they are lying. I find that some people do have the support of good friends or a spouse. They are lucky. Other people find help in DID support groups or in other support groups where people understand pain.

David: For the audience: if you have told someone about your DID, either how did you say it or what was their reaction? I think it would be helpful to many here tonight. I'll post the responses as we go along.

Paula, a few of the audience members would like to know if you have personal experience with DID.

Paula McHugh: No, I don't, but I admire the heck out of people who survive this.

David: Judging from the comments that I'm getting from audience members, I think many feel you really "understand" what they are going through and what they are saying.

Here's another audience question.

Maia: How do you deal with clients who have been hospitalized, and the other professionals do not believe in Dissociative Identity Disorder, which prevents them from being helped or feel safe?

Paula McHugh: That's a tough issue for me. There's one hospital in this town that accepts Dissociative Identity Disorder - and TALKS to alters. The other hospital does not. It irks me! People deserve respect and time to just talk, it helps them let go of worries and move on. I work with psychiatrists who believe what I believe. I just can't ignore alters. I know that seems to work for some doctors and some therapists, but I don't know how they do it. I have to do it the old way, the way Frank Putnam wrote about in his book, "Diagnosis and Treatment of Multiple Personality Disorder". The outlines dealing with alters and helping them. Sorry if I got on a bandstand, but it's something I feel strongly about.

David: And that is a difficult issue because there are professionals, psychiatrists, and psychologists, who do NOT believe in Dissociative Identity Disorder, Multiple Personality Disorder. So, therefore, it's important to find a therapist who does, and I would be very upfront and ask the person directly before I got involved in doing therapy with them.

Here are some of the audience responses to "how did you tell someone else about your DID and/or how did they react once you told them" :

whalevine: Have you ever seen or heard about the movie Sybil? If they say yes, then I tell them I am like that person. If they do not know about the movie, then I tell them I was hurt so bad when I was little, that I made people inside called Alters to survive!

Tyger: Most people thought I was making it up, or got scared and ran away.

patscrew: When I first told my girlfriend I was an alter, she thought I had been neutered!

insight: I have to feel absolutely safe with a person before I disclose. I have had outside family come to a session to learn more about DID, especially those who have to live with me when I switch under stress.

freckles: One good friend has stopped communicating with me after I told her. She just smiled and was non-committal.

TXDawn27: I told my psychology teacher and he was very supportive. He helped me make up the class work I missed while in the hospital.

JoMarie_etal: We usually tell somebody when we feel trapped and it is the only way to explain something, i.e., switch in the middle of a project, etc.

imahoot: The doctors and therapist told my family and friends while visiting me at the hospital and educated them on it.

freckles: I'm fortunate to be in a relationship with another DIDer, and to have friends who are DID. My mom just thought "it's another one of her crazy moods" when I told her I was DID.

danalyn: I have found you must really know and trust a person if you are going to tell them. Telling can cause more hurt and rejection.

TXDawn27: Everything you've said feels so "right" to me. It goes a long way to making me feel less crazy and alone. I agree that trust should be the first priority in a therapy relationship.

David: Here is an audience question:

CryingWolves: I would like to know if the feeling of blending is a step toward, or a part of, the process of integration.

Paula McHugh: I think it's both. Blending is a process of integration. Lines become blurred -- less bold. People who used to be passive - become assertive, people who were just angry - learn to cry and love.

---

David: Here are some more audience responses:

pensive: I don't tell people because it tends to make them look at me differently. I just want to be treated like anyone else.

berrybear: I tell them I've been in a war far worse than any they have ever imagined, and that like war veterans, I have a strong case of Posttraumatic Stress Disorder (PTSD) from it.

sammi1: I lost my career as a nurse. All my friends abandoned me. My daughter, age 16, left home.

JoMarie_etal: We don't even trust each other, and trusting a therapist takes a very long time. They really have to prove themselves. There is NEVER complete trust.

David: I have a question: From what I know, most of the people who have Dissociative Identity Disorder, it developed because they were abused in some way. Is there any other way to develop DID?

Paula McHugh: I heard of a case which developed because of seeing violence and people being killed accidentally, but I think that's very rare. Everyone I know experienced sexual abuse.

David: How common is ritual abuse in Dissociative Identity Disorder cases?

Paula McHugh: All too common. It's a factor in about 1/3 of the cases I have worked with.

oryakos: Question: How does one start to identify triggers BEFORE switching?

Paula McHugh: Time. Time and practice. Also, someone to help you - someone to talk to.

janedid: I am afraid that if we integrate, we will be gone, that we will not know who we are anymore. Does this ever happen, or are all the alters still aware of themselves?

Paula McHugh: I know it's scary at first, but I've never known anyone to be lost, and people stay the same. I mean, they know exactly who they are. At first, they are a blending of "Shirley, Sue, Joe, etc." Later, it's just "me," but Shirley, Sue and Joe are still there. I can see it in the person's action, in their eyes, in their choice of words.

Les M: Is integration considered to be a oneness, or like, if the process happens unconsciously, do we "lose everyone"?

Paula McHugh: Yes, it's a oneness. No, no one is ever lost. I've never seen anyone getting lost. Everyone is there. You can't believe it until you feel it.

David: I'm wondering why, after the trauma that caused the Dissociative Identity Disorder, the splitting and alters, why after a period of time, say a year or more, does one continue to develop alters? And also, without therapy, does that process just continue throughout one's lifetime?

Paula McHugh: Alters develop when there is overwhelming stress. Yes, I think it may continue without therapy. Splitting is just a reaction to anxiety and fear which you can learn new ways of reacting and new ways of coping, so you don't have to split off anymore.

David: What about hypnosis therapy for Dissociative Identity Disorder? Is that effective?

Paula McHugh: I think so. Dissociative Identity Disorder is a mechanism of self-hypnosis. DID people are experts at using hypnosis, even if they don't even know it. Every time there's a switch - it's through hypnosis. Hypnosis in therapy helps people go back and experience the past, then redo the past into a better solution. It helps to relieve the fear, anger, and sadness, and replace it with some safety.

David: Here's an audience question:

Tyger: How do you, as a therapist, deal with satanic abuse? Most people don't believe me when I tell them, so I just stopped talking about it.

Paula McHugh: I believe it happened. Keep trying to find people who understand. I'm not a doctor, I'm a counselor, I just talk to people - no pills.

David: Here's another question:

angel wings: I have one part that so hates the part called Body for what it did, that she threatens to kill us if she is made to share the same physical body as Body. What hope is there that they will ever integrate?

Paula McHugh: Lots of hope. They just need to know more about each other. All that anger belongs somewhere else. It needs to be directed toward the perpetrator - not the inside family. People just don't know what to do with all that anger. They need someone to accept them as they are and listen to why they are so very angry.

JoMarie_etal: How do you work with highly suicidal clients?

Paula McHugh: Sometimes medication helps a little, sometimes the hospital helps. Most of all trust helps. The person has to get to know me and know that I care before they can really talk about why they want to die. Usually, it's the memory stuff that haunts them. When we can clear that out, the world looks better.

trill: Do you ever recommend that DIDers take some pills? Do you send them to psychiatrists? When? Why? What's your opinion on using or not using medication for this deal?

Paula McHugh: Yes, sometimes pills help. It has to help the whole system though. Antidepressants work if they help the right people chill out a little and don't put the little ones to sleep. Yes, I recommend doctors if I think people need them. Dissociative Identity Disorder people taking medications is not at all like other people on medications. It always works differently, and you have to go slow and see if it's helping or not.

---

David: Here are a few audience comments on what's being said:

Tyger: I have mostly child alters and medication only make them sleep. All the other medications hurt my body. Even contemplating the hospital nearly sends me into fits.

Jimmy2of7: Meds don't help all of us, only some of us. It just makes me be quiet.

whalevine: We are allergic to a lot of meds, or some alters will hoard them and then take them all at once.

David: What about the ability to have healthy relationships with other people who do not have Dissociative Identity Disorder?

Paula McHugh: That's perfectly possible if the other people are reasonable and also patient. Gentle is good, reliable is good, it depends on the people. There are some good guys out there, male and female.

David: A few more audience comments on what's being said tonight:

fuffie: Patient, gentle, reliable and a sense of humor!!

dendroaspis: Sense of humor is a must.

Paula McHugh: Humor is WONDERFUL

JJ1: My husband has been my best support.

myrias: I think it's much more interesting when two or three DIDers get together!

Tyger: That's funny, my ex became my roomy after finding out I was DID. He was afraid a child alter would pop out.

JoMarie_etal: Hospitals don't help when you have no money. They are actually too cruel. It just postpones the problems and sometimes makes them worse. We end up not talking about the need to die because of so many bad hospital experiences.

dendroaspis: I wish I could get a tax break on my alters :-)

Paula McHugh: That's humor, dendroaspis. I like it.

myrias: Yeah, like how many dependants do YOU have? Giggle!

Paula McHugh: Good giggle.

trill: It seems to me that I've got someone inside that was an actual person whom I once knew and was once very close with, but he died. The version of him on the inside doesn't seem ever to come out, or at least I haven't received any reports of that or seen any evidence of it, but he keeps me company at different times. What's that about?

Paula McHugh: I'm not sure, but it would be good to ask him.

scrooge027: And how effective is EMDR on treating DID?

Paula McHugh: That's a good thing to use after a client gets through with a lot of memory work. Before that, it seems like it would be too powerful. I only use it later in therapy, when I know how a person reacts in most situations. I don't want to get into more than we can handle. EMDR is great for finishing up stuff in therapy.

David: Well, it's getting late. I want to thank our guest, Paula McHugh for coming and sharing her knowledge and expertise with us. You have been a wonderful guest. And I want to thank everyone in the audience for being here tonight. It's been a great discussion and I appreciate everyone participating and sharing your experiences and questions.

Paula McHugh: Bye everybody. I appreciate the time here, this is one of my favorite topics because I really do care about these folks.

David: If you haven't been to our main site yet, http://www.healthyplace.com, I want to encourage you to visit.

Thank you again, Paula, and good night everyone.

Online Conference Transcript

Melissa Ford Thornton, author of "Eclipses: Behind The Borderline Personality Disorder, joined us to discuss what life is like with Borderline Personality Disorder. She discussed her suicide attempts, self-injury, fears of abandonment, hospitalization, and progress with Dialectical Behavior Therapy (DBT). She also answered many audience questions regarding relationships, medications, and wanting to die but finding the will to live.

David: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Living With and Recovering From Borderline Personality Disorder (BPD)." Our guest is Melissa Ford Thornton, author of "Eclipses: Behind The Borderline Personality Disorder."

For many years, Ms. Thornton suffered tremendous pain because of Borderline Personality Disorder. She describes it as like "living in hell." Although there are still many therapists today who feel that BPD is untreatable or too difficult to treat, Ms. Thornton is living proof that it is possible. She details her life with BPD and recovery from Borderline Personality Disorder in "Eclipses: Behind The Borderline Personality Disorder." You can purchase her book by clicking on the link.

Good evening, Melissa and welcome to HealthyPlace.com. You say life was like a living hell with BPD. Why? What were you feeling? What was life like for you?

Melissa Thornton: Hello to you and our audience. I was first diagnosed with anorexia and had difficulty not dissociating - that is losing my consciousness of being in my own body. It was as if I were watching my life from above with no participation in events, including starvation and cutting behaviors.

David: And you were how old at that time?

Melissa Thornton: I was 29 - perhaps significant.

David: Why do you say that is significant?

Melissa Thornton: I was preparing to enter my thirties and I wanted children with my husband as well as the public relations/writing career I had at that time. Decade transitions can be quite difficult for many people.

David: Prior to that time, had you suffered any sort of mental illness?

Melissa Thornton: I believe, as does my psychiatrist of more than a decade, that I have been emotionally vulnerable and sensitive and had glimpses of childhood molestation, beginning as far back as 17 years of age.

David: For those in the audience who want to know what Borderline Personality Disorder is, please click on the link for a full description.

And so you started dissociating and became involved with anorexia. This must have been scary for you.

Melissa Thornton: Yes. It was terrifying. Since I had not recognized the earlier, overt signs that could lead to this mental disorder I certainly felt alone and that was "hellish" for me.

David: For those people who aren't intimately familiar with Borderline Personality Disorder, can you please describe what kind of behaviors you were involved in and the kinds of feelings you were experiencing?

Melissa Thornton: The formal physicians' diagnostic criteria lists at least five of nine symptom categories for BPD to become a diagnosis. I didn't know this and saw all nine and was afraid I would develop what I didn't already have. As nearly as I can recall, I was very depressed, had low self esteem - sometimes none. I was perfectionistic. I was over-spending (on clothing mostly). I was intensely suicidal with several parasuicidal episodes. I wanted to die. My mother had committed suicide several years before. No one explained that you can recover or live productively with a mental illness or disorder, so I just wanted to save my family from another round of hope and heartbreak.

David: By the way, what year was this when the BPD symptoms started to appear (when you were 29)? And how old are you now?

Melissa Thornton: Ah, you admitted it. I thought you were trying to reveal my real-time age! It began in 1991. I turned 38 in June, 2000.

David: So, it wasn't that long ago. And you were already married at that time. How did your husband react to this?

Melissa Thornton: It wasn't that long ago, and I do have bouts with Borderline maladaptive behaviors to this day. My husband is one strong soul-mate. He has stood by my side every step of the way. I think, emotionally, this has affected him as much or even harder (when I was dissociative or on heavy doses of medication) than it has me.

David: Melissa, let's get to a couple of audience questions, and then we'll talk about your recovery and experiences with DBT (Dialectical Behavior Therapy). Here's the first question:

bordergirl: What is a good description of dissociating?

Melissa Thornton: That's a good question. Dissociation generally refers to the separation (perceived by the person experiencing this) of their mind and body. It is a form of psychosis. It is a loss of the ability to be in touch with reality. Doctors working with abuse victims often say it is a coping mechanism in that the mind cannot handle the reality - molestation, beating, etc. Therefore, the mind goes elsewhere and does not feel current pain/humiliation. Is this helpful? Obviously, I didn't remember the abuse - however, I was suicidal and was cutting my wrists yet I felt no pain at all and it seemed as if this was happening to someone else.

lostsoul19: Melissa, why, specifically, did you want to die?

Melissa Thornton: I did not feel worthwhile at all. I felt I was a failure at work and too unhappy to be a good spouse much less future mother. My mother had suicided (clinical depression plagued her for more than 5 years). That was 5 years before my problems began. I did not know that someone did not die if they were diagnosed as mentally ill. That made it hard for me to avoid the "lie" that "everyone would be better off without me."

David: So, are you saying that you believed that having a mental illness was really like getting a death sentence?

Melissa Thornton: You took those words right out of my mouth. I was so uninformed and confused by multiple diagnoses with the eating disorder invisible to me - I was in denial and pain constantly.

David: One of the signs of Borderline Personality Disorder is inappropriate, intense anger or difficulty controlling anger. Did you experience that and could you describe that for us?

Melissa Thornton: Yes, my poor spouse experienced that! I threw things and had crying and screaming jags that lasted hours at home. At work, I snapped at co-workers which was very unlike my normally optimistic and encouraging personality (so others have said)!

David: Were you aware of these things as being inappropriate and you just couldn't help yourself or were you unaware?

Melissa Thornton: I was aware much later. When I calmed down, often with my husband's encouraging, unflagging love leading me to that point emotionally. I would become so regretful and self-punitive that the cycle of depression and suicidality would begin again.

David: Here are a few more audience questions on what we've discussed so far:

skier4444: How can you be married? One of my biggest problems with having BPD is that I can't have any relationships - I've never had one.

Melissa Thornton: I understand that and know it must be painful. I understand that one of the hallmarks of BPD is instability in relationships or inability to remain in one. I was hospitalized long-term once diagnosed. There, I saw many long-term singles, divorcees, and divorces in progress. I suppose I was more mentally healthy when I married at 20.

missnic: Also, I have met someone and he is real kind, caring, and sweet, yet I feel like pushing him away, but I feel I don't want him away. I feel scared, why? How do I tell him I have BPD?

Melissa Thornton: This sounds like a complex issue for discussion with a mental health professional. Have you read "I Hate You, Don't Leave Me?" That describes the relationship 'push/pull but don't abandon me' feelings pretty thoroughly.

David: Here are a couple of audience comments, then I want to talk about your recovery.

abyss: I am in a relationship with a man I totally love or hate. Relationships are always painful for me. I want to die when I feel that pain. I feel so uncontrollable in relationships.

missnic: I have met people in my life who don't know I have BPD and I'm afraid to tell them in case they freak out and leave me.

SpunkyH: I have the same relationship problem. I functioned well until about 42 - been married to the same man and he is so good to me. I think the reason he is able to be supportive is that he knows how I was before the BPD showed itself.

SADnLONELY: I know how you feel, abyss.

David: Your BPD symptoms started in 1990. What year did you check yourself into Highland Hospital for inpatient treatment and what prompted that?

Melissa Thornton: It was 1991, actually. By April of 1992, my psychiatrist (I'd been locally hospitalized for the physical ravages of anorexia at first) recommended and made it a condition of her continuing as my psychiatrist that I enter either Highland Hospital or New York Hospital, Cornell, after a near-fatal overdose.

David: And what happened while you were at Highland?

Melissa Thornton: That was a miracle. I learned, slowly but surely, the main skills used in Dialectical Behavior Therapy (DBT), developed by Marsha Linehan, a Seattle based psychologist. However, DBT had not been used in an inpatient setting until 1991. My good fortune! I entered this therapy which has clinically been proven to reduce self-harm over time.David: Can you define Dialectical Behavior Therapy (DBT)? What is it. Can you describe the DBT process?

Melissa Thornton: Borderlines tend to think of things in terms of black and white. Basically, things are either so good I can conquer the world or so terrible I am lonely and in pain and want to die. Dialectic means holding or relating to two opposing ideas in your mind at the same time. Thus the DBT is behaviorally based and accepts a person where they are but insists on incremental changes to the point of using the skill "tool-box" offered by Linehan's approach. For example, people would learn to see that Winter might be very cold and an isolating time for some, yet it is a natural seasonal change and allows the ground to be fallow, the sap to lower in trees, and thus allowing a time for post-harvest activities such as tilling the land for food, and trees to be transplanted, and, most importantly, for cozy indoor activities and/or fun adventures even for sufferers of SAD (Seasonal affective disorder) to try skiing or skating, etc. So winter is neither good nor bad; it is neutral or both. I like to think of good/bad things or happy/sad things and find not a grey area but the full spectrum of colors - the rainbow in between black and white.

David: A few site notes, then we'll continue: You can click on the Personality Disorders Community link and sign up for our weekly newsletter, so you can keep up with events like this.

Dr. Leland Heller's site, Life on the Border, is here. I'm also getting some questions on self-injury. We have several excellent sites that deal with many aspects of self-injury: A Healing Touch and Vanessa's "Blood Red" site.

So what you are saying, Melissa, is that DBT is a therapy that allows the person to see that not everything is black and white, good or bad, but there's a grey area where most people live.

Melissa Thornton: That's it on a very basic level. There are many skills and an outpatient DBT groups session includes homework on honing those that work for a person. The idea is to realize that most if not all things are "both" - even if the "both" sound opposite. Life is good but hard - both are true. Is that more clear?

David: Yes. How long did this therapy take to have an impact in the way you felt and the way you behaved?

Melissa Thornton: I was a pretty sick puppy. I was hospitalized long-term. For me, that was close to one year with many subsequent hospitalizations locally. I had to make a safety plan matching inappropriate emotional states to actions - DBT skills I would use. These were reviewed in Highland prior to release and then made contractual (binding) with my very skilled psychiatrist at home.

David: We have a lot of audience questions. Let's get to some of those:

Filly: I am 7 months into DBT (and very thankful to have found it), but sometimes I have trouble finding the willingness to use my skills. Did you find this, and if so, how did you deal with it?

Melissa Thornton: I really do understand motivational problems. However, we both know how painful BPD can be for us. If we've made it through even one really tough episode and lived to tell the tale we can always say: Hey, I've felt this bad (or worse) before. I can make to the other side - if I use my skills, be it making it out of bed, to that doctor appointment, or calling 911 BEFORE self-harm occurs.

SweetPeasJT2: Melissa, what do you think about psychotherapy to deal with those issues that caused the BPD?

Melissa Thornton: I have found that really important in my recovery. Different things work for different people. That includes medication intake or not.

little1scout: Several questions: Are you on any medications currently? Do you regard DID and Borderline as one and the same? Was inpatient treatment important? What is the hardest part of therapy now?

Melissa Thornton: Yes, I'm on several medications - mostly antidepressants and a brigade of mood-stabilizers (in my case a few anti-seizure medications have worked to help my self-control). Dissociative Identity Disorder is one name for Multiple Personality Disorder - likely because so many MPs have DID in some form. Dissociation is a psychotic episode that can be part of many mental illnesses, including BPD to schizoid personalities, etc.

David: For those in the audience, here are the definitions of BPD AND DID. If you read them, you will see they are different disorders.

Can you tell us how you are now, symptom-wise?

Melissa Thornton: Inpatient treatment was imperative for me. I would surely have successfully suicided by now had I not been in such a controlled environment. I'm much much better, thank you. In fact, I am on the books as bipolar (manic-depressive) only. However, I still tend to recognize BPD symptoms, such as lack of appetite, loss of motivation, overspending, and dangerous driving that could be parasuicidal when I feel overwhelmed or under extreme stress. I have been blessed with a baby boy, born in 1, and remained on my medications during my pregnancy. He is just perfect. I feel so blessed that my husband and I have that long-awaited pitter-patter of little feet.

David: Melissa has a two-year-old son now. And I want to talk about that in a minute, too.

Psych_01: After dealing with Borderline Personality Disorder myself and in group atmospheres I have found that it appears that an individual must WANT to get better. Do you feel this is a big part of recovery?

Melissa Thornton: The psychologist and psychiatrist on the BPD ward had clinical data that revealed an early committment to life, i.e. will to live, was the best indication of a successful move toward wellness and or productively living with the illness in much less pain. I want to say that if you don't have that, please don't give up. I didn't. The odds toward suicide were stacked against my survival, but I'm so very glad I am here. Even if I hurt more than I feel others might at times and more frequently, I know my mom would be proud to see me now.

David: That's interesting, Melissa. You went through the eating disorder, the self-injury, the mental torment, the suicidal behaviors. You said your life was a "living hell." How and when did you develop the will to live?

Melissa Thornton: To be honest, one spring day at Highland, when I had the privilege to go to and from my psychiatrist's appointment unescorted and I noticed the sky was blue and the birds were singing and I felt a teeny-tiny surge of happiness. It was probably my response to one of many antidepressants that had finally begun to work for me. That is, they ruled several out one by one and this one seemed to affect me positively. But, I also think I had some skilled behaviors under my belt by then and attribute my life to both.

David: Here's an audience member comment on her DBT experience:

Willow_1: I just finished a DBT program at McLean Hospital. It was wonderful.

Melissa Thornton: That's fantastic. Keep maintaining those skills.

David: Here's the next audience question:

SADnLONELY: One trait of BPD is self-injury. DBT teaches skills to learn other ways instead of self-injury. I am still having the hardest time with this. Did you have this trouble? If so, what did you do to not self-injure?

Melissa Thornton: One DBT skill is to replace the need to feel pain or be self-punitive by swapping a self-injurous item for a painful but harmless item. For me it meant holding a piece of ice in my hand until it melted entirely. This hurts! I also saw my scars stand out from veins turning purple. This made me realize how much I'd hurt myself and mainly others in my life. I simply felt I would not do that again. There are other alternatives: snapping a rubber band against your wrist until you feel calmer, a COLD shower, and painful exercise sessions may work for you.

David: Here are a couple of comments on that subject:

SADnLONELY: I have tried this and the rubber band thing, but it's still not satisfying my need.

SpunkyH: My swapping is cutting my hair. It feels so good to pull it straight up and CUT, but it does me no harm.

David: You are married. You have a 2-year-old son. I am wondering about the emotional bonding process with your son. Did you/are you finding that difficult at all?

Melissa Thornton: Wow! At first, it was very difficult. I had a very happy pregnancy but when that child was in my arms needing me for everything and I couldn't just say, "hang on I need a nap," I suffered a severe post-partum depression. This was so unexpected by me after so many months of happiness - real happiness! So many family members just jumped in and took Ford's (my son) care into their hands. Well, I guess that left me feeling even worse - useless. But he still heard my voice and knew my smell even though I couldn't breastfeed (meds), and eventually I gained enough self-control to show others I was safe and so was Ford. About 3 months into this parenting business we laughed and sang.

I wasn't always the happiest person. I felt so alone and isolated, but I can say I love to bathe that boy and he gets muddy at any chance! I try to be patient and to forgive myself when he willfully disobeys - don't we all? And he runs to hug me in the mornings or to be picked up and says MAMA - his 1st word. Yes, we're very closely bonded.

David: Are you concerned at all about him picking up on your BPD behaviors? And, if so, how do you handle that?

Melissa Thornton: Yes. In fact, I worry about the fact that there is a genetic link to have a tendency toward (not necessarily to develop) emotional disorders and my illness(es) could well have come through my mother's genes. I use a lot of self-control skills and listen to upbeat music when I'm with him. I haven't cried in front of him except once a few weeks ago. He was very upset and patted my face. My husband got angry at me for showing such emotion in front of him. I saw it as a healthy opportunity - to say Mommy's sad. It's ok to be sad sometimes. I know when you can't find your favorite stuffed animal you are sad and a little lonely. That's ok. I hope you always feel you can trust Daddy and me with your feelings and will share them with us. He's only 2 but I think over time this will sink in and help us all be more emotionally aware.

David: Here are a few more audience comments on what we've been discussing tonight:

nomobody: Aren't tears a normal thing? I mean, everybody hurts, not just people with BPD.

Melissa Thornton: So true.

Browneyes83: Do you know if Borderline personality is hereditary? Can it be passed on to your children?

Melissa Thornton: At this time, I am not aware of any scientific evidence proving that. The propensity to be more emotionally demonstrative and sensitive is proven to be genetically passed in some families. Not every family with emotional individual(s) will find that propensity in their offspring. It is just a theory in my case between my mother and me.

David: A few more comments:

Nyoka75: I worry that my husband will eventually get scared off due to the BPD and that I will be alone with no one to help me when I need it. Do you ever feel that way?

Melissa Thornton: Sure. Borderline Personality Disorder brings on abadonment fear oftentimes.

SADnLONELY: The anger is the worst part for me. The slightest bit of anger brings me to a boiling point and it takes control over me. It has me so afraid of hurting others that I must hurt myself in order to stay safe.

SpunkyH: I do push him away. Since we have a brother and sister relationship, I feel so bad because he is a wonderful man and I am not willing to give of myself since the memories have came back. I, like you, want to die the minute I feel that he is not supportive because life is just not worth hurting the ones I love over and over again, but then I realize the truth that me not being here would hurt them more. I learned this through years of psychiatric care.

bordergirl: I can SO identify with the black and white part. I struggle with it everyday. The worst part of having BPD is staying in therapy on a regular basis (for me anyway).

SpunkyH: Boy, I can relate to that. The 'Good or I want to die' switch happens so quick sometimes.

David: Here's the next question:

furby5: Are you able to maintain close relationships with people or do you run away when people get too close?

Melissa Thornton: I tend to maintain close relationships - quality not quantity. BPs tend to be caretakers of everyone but themselves. Some relationships with friends became too unhealthy for me. If I was up they'd bring me down; if I was down they might sink my boat almost.

David: Do you still deal with fears of abandonment?

Melissa Thornton: Yes, I do. Sometimes I dream my husband has taken my son and left me. This has translated into really terrifying clingy behaviors. I finally got a mental analogy that worked for me to stop the clingy behavior or slow me from it. That is when you're swimming underwater (which life with BPD feels like a lot to me), the more you reach out to grasp something - a penny floating down or whatever, the more your own movement pushes it away from you. So, I try to be less afraid of my unconscious thoughts (dreams), but very much on top of my early warning signs of negative behaviors so that I can put my safety plan and skills into motion before I do something that might be pushing my husband away and/or making him feel I am unsafe to be a mother.

David: You have been dealing with mental illness for over 10 years now. A lot of times people come to the site or conferences and ask "when will I recover?," meaning when will all the symptoms go away. Do you still hold out hope for that or do you believe it's a matter of managing the symptoms for the rest of your life?

Melissa Thornton: I do want a full recovery, but I have learned from several doctors that I will likely be on medication for my lifetime. I also know from Highland Hospital studies that as we grow older with BPD we can "outgrow" the worst symptoms. In fact, some Borderlines have reached the point - 75% of the known BPD population, in this aging group in fact - no longer meet the diagnostic criteria for the illness. So there's always hope. But to live hopefully is a life worth living. Not hoping for full recovery, I believe.

David: And when you say "grow older," at what age are you talking about when you outgrow the symptoms or many of the symptoms?

Melissa Thornton: That's a grey or "rainbow" area, David. The Highland studies found that those approaching 50 and having had the illness and professional help for it for at least 5 -10 years met the criteria for the 75% recovered group.

David: One of the other things I noticed is that you keep track of your moods, symptoms, behaviors, feelings; like you monitor your condition so you know when things are off kilter and you need to take some positive action. I don't know if you have ever heard of the author Mary Ellen Copeland, but this reminds me a lot of what she advocates as part of her "wellness plan."

Melissa Thornton: Yes, I have seen her work book. I journal - maybe a natural outgrowth of being a writer by trade, but others help me as well. My husband mentions when he thinks something is off and it might really hack me off but then I reflect or look over journal entries and/or ask a close friend and usually apologize and thank him for his insight.

David: Melissa's book is: "Eclipses: Behind The Borderline Personality Disorder." It can be purchased by clicking on this link.

Some kind words from an audience member for our guest tonight:

missnic: I wanna thank you Melissa. I have always felt so alone and different and isolated, but after seeing everyone here and reading your chat I don't feel so alone or so different. It has helped. Thank you.

David: Thank you, Melissa, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people in the chatrooms and interacting with various sites. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Melissa Thornton: Thank you for having me this evening. I learned a good deal and feel less alone also.

David: Thank you again, Melissa. I know you were a bit nervous at first, but you did a wonderful job and we appreciate you coming tonight and staying late. Good night, everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Our guest, Anne Pratt, Ph.D., is a clinical psychologist at the Traumatic Stress Institute. Her expertise centers around psychological trauma and Dissociative Identity Disorder (Multiple Personality Disorder). The discussion focuses on getting your alters to work together.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "DID/MPD: Working Within the Multiple System". Our guest is therapist, Anne Pratt, Ph.D., a clinical psychologist at the Traumatic Stress Institute, a private mental health organization devoted to research, treatment, and training of other professionals in the area of psychological trauma. Dr. Pratt has worked in the field for fifteen years, and has extensive experience with Dissociative Identity Disorder. If you are unfamiliar with DID, MPD, here's a link for a further explanation of dissociative identity disorder (a.k.a. Multiple Personality Disorder).

Good evening, Dr. Pratt, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. I can imagine that having several alters within can become very disrupting, making it difficult to live a "normal" life. Because everyone in the audience tonight may not be DID/MPD, but may be just friends or family members, can you give us a description of what it's like living in a fragmented way?

Dr. Pratt: Good evening. I will try! People with Dissociative Identity Disorder differ considerably from each other, so this description won't fit everyone with DID. People with DID who do not have what is called co-consciousness (awareness of what is happening when other alters are out) experience significant disruption in their lives, through amnesia, and through finding out that they have behaved in ways that they don't usually behave.

David: And the result of this is what?

Dr. Pratt: Sometimes a person with DID is called a liar because people accuse them of doing things that they deny doing. Sometimes they are viewed as weird or flaky because their behavior is so variable. Their internal experience is that the world is kind of unpredictable, difficult to navigate at times.

David: Tonight, we want to discuss getting your alters working together towards a common goal, whether it be healing or just everyday living. Is that even possible or reasonable to expect that to happen?

Dr. Pratt: Oh, yes. It sure is. When people can get their alters to agree on things, life gets much easier and less disrupted. It's a difficult goal for many to reach, but not impossible. Alters were created because there were things that were too hard for one person to accept what happened to them. So, the barriers between alters, barriers between knowing what one or another is thinking or doing, are there for a reason. When the barriers get in the way, though, and disrupt one's life, it is more helpful to have openness within the system.

David: Is this something that can only be accomplished in a therapeutic setting?

Dr. Pratt: I don't think it can only be accomplished in therapy, but if the therapist is experienced in dealing with dissociation, it sure does help. I expect that many people accomplish this outside of therapy, but we therapists, just don't know that much about it because we only see people in therapy.

David: A moment ago, you used the term "openness within the system". What does that mean?

Dr. Pratt: By that, I mean "internal communication," or communication among alters. Internal communication is the first step toward cooperation.

David: How does one accomplish internal communication amongst the alters?

Dr. Pratt: For many people with multiplicity, it is a difficult task. This is because, as I said earlier, the barriers between alters are there for a good reason, self-protection. But for others, it is relatively easy. If the person wants to establish communication, but can't "hear" others inside, they might start by writing to each other in a journal.

I'd like to add, that if you contemplate doing this, please check it out with your own doctor. This isn't a good idea for everybody at different stages of treatment.

Others, who can hear each other, might start trying to have conversations about their different needs and wishes. It's a little like getting any group of people to work together. You find ways to get the word out, and then you take care to listen carefully to each other.

David: As you can imagine, we have a lot of audience questions. Let's get to a few and then we'll continue with our conversation:

Dr. Pratt: Sure.

saharagirl: How can one get alters to work together when they have different loyalties?

Dr. Pratt: Saharagirl, that's a good and important question. I think that different loyalties are one of the primary reasons why this doesn't happen quickly or overnight. Alters (and the "host") need to respect each others' loyalties, needs, and wishes. Like any group of people who experience conflict, this is not easy. But if those who are trying to accomplish internal communication and cooperation keep emphasizing respect for everyone's point of view, it will help. Even those alters who have seemingly self-destructive points of view have them for a reason. If their reasons are understood and respected, it will build a bridge to working together toward mutual goals.

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Chandra: I have a seven-year-old alter that cuts me after I do anything that she perceives is not safe. How do I deal with that?

Dr. Pratt: Chandra, you bring up another common problem and one which makes working together really difficult. Obviously, it's really important to help this little one feel safe, to help her define what she needs to feel safe, and to assist her in getting that safety. It's not an easy or a short-term problem, but when she starts to feel safer, she will be more able to relax and let older ones make decisions. Even if they feel a little risky to her. I guess the short answer is, negotiate (easier said than done, I know).

David: I know that this is sort of controversial, but just so we know and understand where you are coming from Dr. Pratt, is "healing" to you the same as "integration" of the personalities, or is it getting the alters to work and exist together?

Dr. Pratt: I think that everyone needs to define healing for themselves. I cannot dictate my idea of what healing is to another person. I personally believe that doctors have made too much of the idea of integration. Many multiples, if they are able to cooperate internally and are not losing time or missing what is going on when others are out, can live completely satisfactory lives without trying to integrate. If someone chooses to work toward integration, that is certainly their option. If they choose not to, I would support that decision too.

asilencedangel: I have a very angry alter in the system who is both mentally and physically disruptive and violent. I have been trying to contract with her, or reach her in some way, but have been unable to. Do you have any suggestions in obtaining a contract or communication with her?

Dr. Pratt: Asilencedangel, you are describing one of the most difficult problems to address. I would make the same suggestion, though, with perhaps the added encouragement to persist, and keep on persisting.

The way to open communication with alters who seem opposed to the goals of the rest of you, is to discover his/her goal (like the goal of Chandra's 7 year old alter was safety, even though she was doing something that some would define as unsafe) and try to make suggestions about how to reach that goal that both of you can agree with.

It's not easy and I won't pretend it is. However, the key is definitely, "I disagree with your method, but I think we may have something we do agree about." It's usually keeping safe, not getting too close to others, not remembering. That's what "destructive" alters are usually after.

David: If one can't consciously watch over the other alters, how can you work with them?

Dr. Pratt: This is where the help of a therapist sure comes in handy. A therapist experienced with DID and dissociation can help the person's alters begin to feel some trust, and begin to come out to the therapist. As that happens in the very beginning, sometimes the therapist is the conduit for communication between alters. That's not a good way for treatment to proceed, however, and the goal should be to help alters communicate with each other through written, or ideally, internal words. As soon as possible.

Falcon2: How do you teach alters to do specific things when you are not co-conscious?

Dr. Pratt: Falcon2, I guess the answer is, you try to communicate and really try to listen. What do the others need or want? What do you want of them? If internal communication isn't happening yet, you keep trying, and in the meantime, get help from a therapist or a written journal to try to communicate that way. I don't know if you can teach alters to do specific things. But you might be able to ask them to do "x" for you if you can do "y" for them. For example, they will refrain from drinking, if you can give them some time for recreation for themselves.

David: Here are a few audience comments on what's been said, so far, tonight. Then we'll continue on.

katmax: I am co-conscious and it has taken long time and lots of good therapy. I have seven alters.

Sonja: The alters I have can't agree on anything!

cherokee_cryingwind: I am a survivor of incest with six alters, one of which, used to be very destructive.

David: Besides the journaling, what other ways are there to establish a workable system of existence with your alters?

Dr. Pratt: I think that the help of a therapist is really useful in helping people develop internal communication and cooperation. Sometimes the therapist is the one who can most easily recognize the common goals, from alters who seem to have very different goals indeed.

David, as is so often the case, there is lots of expertise in the room, and it certainly isn't all mine! These comments illustrate how much good information multiples can get from each other.

David: I agree :)

We B 100: I've found, that allowing alters to have their times, they tend to work better together and communicate more to the others.

Dr. Pratt: I would have to underscore what We B 100 said, that giving alters their own time to do their own thing is a very positive step. Sometimes the trouble increases in a multiple's system because different parts' needs aren't being met. Everyone, multiple or not, has different needs, and in a multiple, meeting the needs of alters is one way to keep everyone settled down and willing to work together.

David: Regarding "meeting your alters needs," here's an audience comment, then we'll go to more questions:

toomany: Just like outside children, you give them a little and it goes a long way.

Dr. Pratt: :)

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David: One of the common questions we are getting, Dr. Pratt, is how long should it take to obtain a peaceful coexistence with your alters?

Dr. Pratt: I wish I could answer this to everyone's satisfaction. I'm not sure I can. I think, if the person has alters who are doing highly destructive, scary things (like intensely suicidal or self-injurious behavior, severe addictions or eating disorders, to name a few, it may take a few years to get it all settled down. Sometimes more than a few. If, however, the individual's life is only mildly disrupted by the multiplicity, treatment can help things settle down dramatically in maybe six to eighteen months. Not everyone with multiplicity experiences these very difficult adaptations. There's a lot of differences among multiples.

milo: Does gaining cooperation and communication with your alters, whether through therapy or simply journaling, always have to involve rehashing the past?

Dr. Pratt: Oh, Milo, what a good question. The short answer is, No. But I'm not good at short answers! The goal of internal communication and cooperation might be accomplished with almost NO rehashing of the past. But the reasons why alters do various things, and the reasons why one has alters to begin with, will probably mean some thinking about and talking about the past. That's as short as I can do it!

Kimby: Where is the Traumatic Stress Institute located and do they work with SRA/DID individuals?

Dr. Pratt: TSI is in South Windsor, Connecticut. The psychologists at TSI do work with these folks.

jewlsplus38: The 'core' has recently had to feel intense grief for the first time and has buried herself again. We are at a loss as to what to do to try get her back. Our job, up until now, has been to teach her how to live, and we feel very alone. Did we give her too much?

Dr. Pratt: Jewlsplus38, I think you are most likely doing a great job. I would guess that, if all her life she has dissociated strong feelings, the process of learning to feel them for the first time is going to be on-again/ off-again. Offer support when she reappears, and keep her life in order while she is away. I can't say for sure, but you sound very caring and careful, and I think you are probably on the right track.

oak: How does one work with alters who refuse to be drawn out to talk with either the therapist or other alters?

Dr. Pratt: Oak, that's a tough question. It reminds me of my first question tonight and the answer is very similar: Make sure that there is safety for those alters. If you (or anyone inside) has an idea about what those alters might need in order to feel safe, then I would try to create that safety. And make sure that it is communicated to them that it is up to them. They can come out when it feels right to them.

JoMarie_etal: Prior to about six years ago, we were at least communicating and cooperating to some extent. Then something terrible happened to us and it totally destroyed all trust inside and out. I have been trying to reestablish some communication and cooperation, but everybody went into their own protective shells and there is extreme resistance to any kind of cooperation. In fact, there is a lot of energy going into disrupting day-to-day living. Is there any way of reestablishing communication and getting everyone to work together again?

Dr. Pratt: JoMarie_etal, you are also describing one of the hardest situations to deal with. A new trauma on top of all the old has to be one of the hardest things for all of your alters to cope with. They were partially convinced that cooperating and communicating (breaking down the barriers among them) was a good idea, and then something awful happened and they went back to what they know best.

It comes back to safety again, and perhaps, a strong dose of not blaming. I wouldn't blame any of them for what happened or for pulling back. Try to make it safe to be out again, safe to be talking together again, and stress that everyone has the same goal: keeping safe and not letting bad stuff happen. Then try to focus on ways that everyone can agree to accomplish that goal. Best of luck.

Wind: How do you feel about locking away a destructive alter for a period of time in order to gain co-consciousness?

Dr. Pratt: Wind, I'm not sure I understand. I do know someone who has had some success with locking away destructive alters, but I have never suggested it, or witnessed it myself. If there is a place where the destructive alter can wait safely, apart from others, I guess that's the direction I would go in. But again, without knowing you and the particular circumstances, I'm in the dark, so it's kind of guessing on my part. Talk with someone you have confidence in and who knows your situation well.

David: An audience member says she talks with a DID friend by phone almost nightly. Her friend switches a lot and she wants to know how she can contact the core/main person to continue the conversation?

Dr. Pratt: If possible, that is something she should talk over with her friend. If it is okay with her friend, she might try saying something like: "I was talking to "X" about "Y." I am happy to talk to you later on (if that's true), but right now I'd like to finish what "X" and I were talking about. Is that okay with you?"

You have to be cautious because traumatized people are sensitive (and most DID people have a history of severe trauma). They will perceive rejection in the smallest comments. So, I'd first recommend talking it over with the friend and asking for her suggestions. And perhaps talking it over with the alters and asking them for their suggestions so that, the conversation can be more fluid and less switchy for the caller.

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Grace67: What do you suggest for people on the "low end" of Dissociative Identity Disorder who have such a hard time believing themselves and what is happening in their lives? I am thirty-three and recently diagnosed. My alters do not have the depth of other's alters, yet are each their own. I struggle daily with believing myself (we are co-conscious, although there is little dialogue, there is no amnesia).

Dr. Pratt: Grace, the tendency to disbelieve one's own experience is not limited to people like you describe yourself, who are at the "low end." Disbelief is rampant in society and rampant in the consciousness of every survivor of interpersonal trauma. Just like society, survivors and those who work with them, do not want to believe that it could be true. And DID-like symptoms, or Dissociative Identity Disorder, are part of the picture that we don't want to believe is true.

In some ways, one's disbelief protects one from having to believe it too much, all at once. So stay calm, know that you will probably move from believing in your experience to disbelieving, to being unsure, to believing again. It's part of the experience of surviving interpersonal trauma.

David: Grace, so you know that you are not alone, here are a few audience responses to your comment:

jewlsplus38: I have over eighty alters, and I still go through small amounts of time where I wonder if I made it all up.

JoMarie_etal: We call that disbelief a form of denial and to make it not feel so terrible. Joking about floating down the Nile in Egypt helps to realize that it is a common thing.

engberg: I am in total denial of my DID and don't even want to discuss it with my therapist because I don't want to admit it. I want to lead a normal life now and I feel like if I get into things, I will be too overwhelmed and won't be able to handle it.

Dr. Pratt: Denial is a necessary part of living with a history of trauma.

David:Thank you, Dr. Pratt, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful.

Dr. Pratt: I have really enjoyed this chance to listen and talk with everyone.

David: Thank you again, Dr. Pratt and everyone in the audience. I hope you have a pleasant rest of the evening.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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online conference transcript

Dr. Sam Vaknin: is our guest. He has a Ph.D. in philosophy and is the author of the book Malignant Self Love - Narcissism Revisited. We talked about Narcissist Personality Disorder (NPD), victims of a narcissist, inverted narcissists, and other narcissism topics.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good afternoon. I'm David Roberts. I'm the moderator for today's conference. I want to welcome everyone to HealthyPlace.com.

Our topic today is "Narcissistic Personality Disorder". Our guest is Sam Vaknin, who has a Ph.D. in philosophy. Dr. Vaknin is author of the book: "Malignant Self Love - Narcissism Revisited". The book gives an in-depth look at Narcissistic Personality Disorder, NPD. Dr. Vaknin, a self-professed narcissist, calls the book a "documentation of a road of self-discovery".

And, in the end, although he documented everything and realized he has NPD, he's not any healthier for it. "My disorder is here to stay, the prognosis is poor and alarming." You can read more about Dr. Vaknin here. His site, Malignant Self Love, is in the HealthyPlace.com Personality Disorders Community.

I know you are overseas, in Macedonia. Good Evening, Dr. Vaknin, and welcome to HealthyPlace.com. We appreciate you being our guest today. So that everyone knows what we're talking about, can you please define Narcissistic Personality Disorder, NPD, for us and how it differs from someone who may have narcissistic episodes or tendencies?

Dr. Vaknin: Everyone is a narcissist, to varying degrees. Narcissism is a healthy phenomenon. It helps survival. The difference between healthy and pathological narcissism is, indeed, in measure.

Pathological narcissism and its extreme form, NPD, is characterized by extreme lack of empathy. The narcissist regards and treats other people as objects to be exploited. He uses them to obtain narcissistic supply. He believes that he is entitled to special treatment because he harbours these grandiose fantasies about himself. The narcissist is NOT self-aware. His cognition and emotions are distorted.

David: In your book and other writings, you paint a very undesirable picture of a narcissist as someone who lacks empathy, uses others to fulfill their own ego needs, a pathological liar. What kinds of problems does this create for the narcissist and can they be treated at all?

Dr. Vaknin: Narcissism cannot be treated. The side-effects and by-products of narcissism, such as depressive episodes or obsessive-compulsive behaviors can. Psychodynamic therapies have very limited success in treating NPD and cognitive behavioral therapy (CBT) doesn't fare much better. Medication can be used to treat the side-effects I mentioned. The narcissist is the prime and first victim of his own mental constitution. His disorder prevents him from materializing his potential, from having mature, adult relationships and from enjoying life. The narcissist is universally hated or despised, prosecuted and cast out. He pays dearly for what, in essence, is beyond his full control.

David: From an outsider's point of view, the negatives of being a narcissist, the inability to have mature relationships and enjoy life, may sound bad. But does the narcissist him/herself feel bad about that?

Dr. Vaknin: Recent research shows that he does (he is ego-dystonic). He interprets away his destiny (=bad feelings), he invents complex narratives and employs a myriad of defense mechanisms such as intellectualization and rationalization. In short, he lies to himself and to others, projecting "untouchability", emotional immunity and invincibility. However, this is all a facade which cracks when the narcissist is faced with a real-life crisis, as I did.

David: I read through most of your faqs on your site and one of the things that struck me was, it seems the narcissist only suffers relatively short episodes of feeling bad whenever a "life-crisis" comes up, but then recovers relatively quickly. Is that true?

Dr. Vaknin: Yes, absolutely. This is why it is near impossible to have a long-term treatment plan and therapeutic alliance or contract with the narcissist. He simply doesn't stay put long enough. He "recovers" the functioning of his defenses very quickly and devalues the therapist.

Narcissism is a resilient and pernicious phenomenon, deeply ingrained in the psyche of the narcissist, or as they say in DSM land: "all-pervasive". The reason is that narcissism is not merely an agglomeration of defense mechanisms. It is a way of life, a religion, an ideology, a catechism all rolled into one. It is very akin to drug addiction in its psychological dimensions and, indeed, dual diagnoses (narcissism and substance abuse) are very common as is co-morbidity (narcissism with another mental health disorder). Narcissism is also at the root of a few other mental health disorders. This makes it very intractable.

David: Can the narcissist have a meaningful life?

Dr. Vaknin: Frequently Asked Question Number 1... LOL. The narcissist feels that his life is meaningful as long as his self-deception holds. But when a narcissistic injury occurs (following the loss of a major source of narcissistic supply, for instance), the narcissist is faced with the void that is his life: the empty, dark, all consuming black hole that is at the core of his emotional apparatus. Life without emotions is artificial intelligence. No wonder the narcissist compares himself constantly to computers and other automata.

David: We have some audience questions and then we'll continue with our conversation:

Dr. Vaknin: My pleasure.

SAGUI: Have you ever done any kind of psychotherapy?

Dr. Vaknin: Yes, twice. Once as an adolescent and once in jail. Oops! Forgot a third time, after I broke up with my first girlfriend. None of them went anywhere. I co-opted (bribed, bought off) and then devalued one of the three, discussed psychiatry with another (hence "Malignant Self Love") and became the therapist of the third ... LOL.

Very few therapists know the first thing about pathological narcissism and NPD. The disorder has been classified as a separate mental health category only as late as 1980 (DSM III). Freud did some groundbreaking work and so did Kohut and, later Millon and Kernberg. But these were "lab" types and didn't filter down to practitioners. Additionally, the boundary between NPD and other personality disorders (such as Borderline Personality Disorder, Histrionic Personality Disorder, or Antisocial Personality Disorder) all in the infamous Cluster B - is very blurred.

David: How long were you in therapy (total time) and did you get anything positive from it?

Dr. Vaknin: Well, as I said, no. I didn't derive any discernible benefits, except that I was able to label myself, finally. All therapies were short (the longest was six months) and rather erratic. But labeling myself has helped me get to know myself and, so, maybe it wasn't all in vain. One should not confuse, though, self-knowledge with healing. To heal, one must experience insight and it's emotional correlates. KNOWING is not FEELING and there is no healing (transformation) without the latter.

David: Is there a difference between male and female narcissists?

Dr. Vaknin: Not really. This is why I keep using the politically incorrect male voice ("he", "him", etc.). Still, 75% of all diagnosed NPDs (1% of the population) are MALES. Females tend more to Histrionic Personality Disorder (which, in my book, is another form of NPD where the narcissistic supply is sex and the physical).

David: Here are some more audience questions.

Forgetful: What would be the best way to relate to someone with NPD?

Dr. Vaknin: What do you want to achieve? Who is the narcissist? A boss, a lover, your kid, the neighborhood bully?

Forgetful: A friend and a co-worker.

Dr. Vaknin: If you wish to preserve and maintain the relationship, do not criticize or disagree with the narcissist. Provide him or her with ample and recurrent narcissistic supply (adulation, admiration, attention, affirmation, applause). Never give advice unless explicitly asked to and, even then, make it seem like the narcissist found it by himself. Never remind him that he is weak, sick, unknowledgeable, in need of help, or otherwise beholden to someone or something. Do not threaten to abandon him, do not pose conditions, or impose. Do not intrude, or micromanage his life. Stay away until summoned. Be there only when requested. Do not have a full-fledged existence, being, needs, or wishes of your own.

David: How does one recognize a narcissist (and I'm talking about someone who has an untrained eye)?

Dr. Vaknin: FAQ #58 is dedicated to that, and it is a long one. The narcissist is a master of disguise. He is a charmer, a talented actor, a magician and a director of both himself and his milieu. It is very difficult to expose him as such in the first encounter. But here are a few signs:

1. displays haughty behaviour
2. has a tendency to humiliate, criticize and belittle others
3. has a tendency to exaggerate, small, unnecessary lies
4. has a tendency to fantasize about unlimited success
5. brags incessantly, to ignore you, not to listen
6. has a tendency to idealize you much beyond the call of courtship
7. makes promises which are incommensurate either with the event, or with his ability to fulfill them
8. has haughty body language

David: But there are also people, as you describe, who are "genuine" in nature. So, I'm assuming that by the time one finds out they are involved with a narcissist, it may be too late to dodge the hurt, if it comes.

Dr. Vaknin: I don't know what you mean by "genuine". Anyone who is "genuinely" like I described is a genuine narcissist. Invariably, you feel something wrong on your first encounter with a narcissist. There is something fake, cheap, not authentic, two dimensional in his behaviour, even in his looks. Everything is bigger than life. If he is polite, then he is aggressively so. His romantic nature will tend to schmaltz. His promises outlandish, his criticism violent and ominous, his generosity inane. Something doesn't fit. But we all want to find the right one, prince charming, the savior. It is sad. It is the fear of our loneliness which drives us into a hell much worse than any solitude.

David: I was referring to the "talented and charming" part of the person. Here's an audience comment and then we have a question someone emailed in.

rainmaker: Sam, I spoke to you over two years ago about my NPD fiance and after evaluating the situation, you advised me to immediately throw in the towel and move on. It took me two years to heed your advice and escape the long shadow of the NPD. You were totally right. NPDs can't change as their emotional wiring harness cannot be accessed by mortals. Your advice is so sound: "Just work on changing yourself and trying to understand why you are drawn to a person with Narcissistic Personality Disorder in the first place." You gave great advice.

Dr. Vaknin: Thank you. I am glad I could be of help.

David: This is an email question from C.G., who says "I am 'in love' with someone that I think may be narcissistic. I want to know what these type of men look for in a mate. I guess I am willing to lose myself in order to have him fall in love with me. I get no feedback whatsoever, even though I know that he does care (I have at least gotten that much out of him verbally) as much as he is capable of. I basically am a 'pleaser' and put the other person first in any type of relationship. I find this to be natural, wanting to make others happy. Does this mean I am an 'Inverted Narcissist'? If so, do we just feed off of each other? And if that is the case, couldn't this actually fulfill both of our wants and needs?"

Dr. Vaknin: Not every pleaser is an inverted narcissist. To "qualify" as an inverted narcissist, one must be willing to self-sacrifice. The inverted narcissist forgoes her own needs and wishes and subjugates them to those of her narcissist. She learns the art of "UN-being". She collapses into a shadow, a marionette, skillfully at the mercy of the whims and pleasures of her puppet master. If you wish to hold on to your narcissist, become his "pusher", his drug dealer. He is addicted to a drug called "narcissistic supply." Give it to him, but remember: drug dealers are interchangeable. Someone may come along with a purer, crystalline version.

vielen: When a narcissist abandons someone, can he erase them totally out of his memory? And does he want to?

Dr. Vaknin: Yes, I did that with my ex-wife. Actually, there are two typical reactions:

1. One is, to totally erase and delete every shred of a remnant of a shadow of a memory of her and the common life (the more common reaction).
2. Or as vindictive narcissists do - to stalk, pursue, invade, control, threaten and manipulate the ex.

See the relevant FAQ about "Vindictive Narcissists".

David: Is there a common characteristic, common personality trait, among the victims of narcissists?

Dr. Vaknin: Yes, their submissiveness and eagerness to please. This is because the narcissist becomes their drug, their addiction. Without him, it is a world of black and white. With him, it is a Technicolor show, complete with drama, thrills and frills. So, the inverted narcissist and the victims of narcissists (not all of them inverted narcissists), are attracted to excitement, to the violation of routine, to life itself. They live vicariously, by proxy, through their narcissist.

David: Dr. Vaknin's extensive list of frequently asked questions is here.

luke1116: HELP! Any advice on how to cope with my NPD ex-husband, with whom I share joint custody? He belittles and berates me daily in writing and I'm afraid that he's doing it during his visitation with our daughter.

Dr. Vaknin: He most probably is. But then, this behaviour is not necessarily limited to narcissists ...:o(( Narcissists are paranoids and cowards. If you were to find a way to show him that you are strong and are willing to use your strength, the harassment might stop. Leave it to his imagination what you might do to him. But make clear that you are going to do something about it.

But I must add that narcissists rarely go where they experience frequent or recurrent narcissistic injuries. Ask yourself what have you been doing to provide him with narcissistic supply. Your fear and humiliation give him the feeling of omnipotence. Are you ambivalent about your separation? Are you in pain? Can he see this pain? Are you sorry he left? Can he see that you still love him? Make his encounters with you a source of humiliation and narcissistic injury for HIM!

Jacqui B: What are the lasting effects on adult children of narcissists? Is there any hope for them to break free from their upbringing?

Dr. Vaknin: Yes, of course there is. Only a very small fraction of children of narcissists become narcissists themselves. What rarely goes away, is the pain and the agony of being treated like an object, of being subjected to psychological torture and nefarious mental abuse. This is part of the psychological baggage of every child of every narcissistic parent. Therapy sometimes helps and ameliorates. But the problem is that it is impossible to obtain closure with an narcissistic parent. He, or she, simply will not admit that they did anything wrong. They will deny, rationalize, intellectualize. Project anything, just to accept the bare facts and confront them in a constructive manner together with the hurting child.

Rena: I allowed my father much control over my life. I'm thirty-eight now and realize his narcissism. How do I limit his control without disowning him? Is it too late?

Dr. Vaknin: It is never too late to set oneself free. But liberty always has a price. Sometimes you can make peace with your oppressors, sometimes you can't, and YOU have to let go. It is a tango - you are BOTH engaged in this macabre dance. Stop the music. Set boundaries. Declare independence. Legislate. Fight for your rights. And if he persists, say goodbye.

David: Here's another email question. This is from Jill. Can you please explain how to reason and negotiate with a narcissist, whether it be a serious subject or everyday conversation?

Dr. Vaknin: That's a tough one. The narcissist is autistic. He inhabits in his own universe. In this universe, a unique logic prevails. You have to learn the language and then the meta language and then exercise some. To be more helpful: you offer to him narcissistic supply and he will give you whatever you want. It is that simple. Make it look like all the initiative is his, all the ideas are his, all the control is his, all the decisions are his. His, him, he - the three keywords. Not you, HE. Manipulate him. Example: if you want him to learn something new (of which he has no idea), ask him to explain it to you (put him in the position of the teacher, the guru). If you want him to attend marital counseling, tell him you need help and you need HIM to help you.

campbet: When dealing with a person with Narcissistic Personality Disorder, what tactics can be used to make this person take responsibility for their actions?

Dr. Vaknin: The narcissist has alloplastic defenses. What this means is that he tends to blame others, inanimate objects and people, for his behaviour. "You made me do it" is a common sentence or, "What could I do? I couldn't help it under the circumstances." He is superstitious to some extent and paranoid ("The world/luck is against me").

Again, the key is simple: the narcissist is a vending machine. Input the coins of narcissistic supply and press the right button ("responsibility"). Example: the narcissist made a mistake. You want him to acknowledge his responsibility. Make the mistake GRAND, unprecedented, unique, amazing, stunning, and the narcissist will immediately "adopt" it. Narcissistic supply can be both negative or positive. To write the masterpiece of all time is the exact emotional equivalent of writing the flop of all time. To be a Hitler is identical to being Jesus. The narcissist has no moral or emotional preference between these two. He just wants to be considered the unique-st.

David: What you're saying is, much like a child, any attention, positive or negative, is good for the narcissist.

Dr. Vaknin: Yes, precisely. The narcissist's personality has frozen in time in his early childhood or early adolescence. He is an emotional fossil. Unable to grow, unable to interact, caught in the amber of his own delusions and rage.

Pollyanna: Dr. Vaknin, in your opinion, is it possible for a Somatic/physical narcissist to ever be monogamous?

Dr. Vaknin: A somatic narcissist derives his narcissistic supply from his body, its functioning, his health, his looks, but above all, from continuous sexual interactions (in which he manifests sexual prowess). It is no good to limit one's sexual interactions to one person. One person is not a representative sample and the narcissist is on a constant polling mission. He collects the opinions of his sexual partners and creates a composite from which he derives supply. Somatic narcissists are very unlikely to be monogamous, although they are very likely to maintain emotional attachment to one preferred woman (man) and regard all other sexual partners as objects. The somatic narcissist is a misogynist. He regards women as tools. The female somatic narcissist (more commonly known as Histrionic) is a man hater. The narcissist maintains a dichotomous picture of "holy-whore". The significant other is holy (and, therefore, should not be contaminated by sexual intercourse). All other women are whores and sex with them tends to acquire sado-maso hues.

David: Judging from the questions, I would say many of the people in the audience are "victims" of narcissists. So, I think here, it's important to point out that getting help for yourself is important.

Dr. Vaknin: Professional help is essential! You do not have to stay in an abusive relationship or a relationship that is harmful to you psychologically or physically. Victims of narcissists often suffer from Post Traumatic Stress Disorder. PTSD is treatable successfully and as David said, stay out of abusive relationships.

David: Here's an audience comment, then another question:

Pris: My NPD husband has been forced to grow because he lost his toy when we discovered my Dissociative Identity Disorder and ritual abuse history.

David: This email question comes from Herb Janssen. "People that I know have narcissistic traits that include lack of empathy, need for excessive personal attention, use of lies to exaggerate their accomplishments, inability to appreciate the needs of others, etc. These run counter to the teachings of most major religions. Based on this, I question the ability of the narcissistic individual to really accept the religious teachings they profess. Is there any information in the literature on the topic of narcissism and religion? Do these people use religion as an escape (I'm okay, I'm a religious person.) or do they really strive to meet the religious teachings?

Dr. Vaknin: Narcissists use anything they can lay their hands on in the pursuit of narcissistic supply. If God, creed, church, faith, institutionalized religion can provide them with narcissistic supply, they will become devout. They will abandon religion if it can't. They abuse religion as they abuse everything else: political office, positions of authority (there's a FAQ dedicated to this) their life circumstances, access to information, other people. They are predatory because they need the supply, not because they are malevolent (most of them are not). They are not evil (as Scott Peck would have it). They are addicts, simple. And religion, as Marx taught us, is a great source of opium. Unfortunately, there are no published texts I am aware of regarding narcissism and religion (with the exception of texts about religious cults and sects).

David: What causes someone to be a narcissist, have Narcissistic Personality Disorder. It is a learned behavior or genetic in nature?

Dr. Vaknin: Dr. Anthony Benis believes that it is of genetic origin. Being the hardware that we are, it is both possible and plausible. It is a fact that not all abused children become narcissists. Also, recent research has demonstrated the incredible plasticity of the brain. But there is insufficient data to support this theory. There are mountain ridges of data regarding the connection between childhood abuse, or bad parenting, or abuse by peers, and the development of narcissism. Pathological narcissism is an escapist reaction to the unpleasant facts of life. It is adaptive. It aids survival. It works. That is why it is difficult to get rid of it. It was functional in a critical period of one's development. I dedicated many FAQs to these questions (especially 64 and 15).

David: Here's a related question on the "passing on of narcissism."

lglritr: Dr. Vaknin, I'm in the process of a divorce from a narcissist who is the product of two extreme narcissist parents (one of which recently passed away). How do you protect an eleven year old child from their influence? I'm worried that I'm beginning to see an onset of some of the traits.

Dr. Vaknin: Nothing to do except serve as a counter-example. Show your kid that there is an alternative. That not all people are so self-centered and merciless in their pursuit of gratification. Be the kind of person you want him to be. Give him a choice. But do not choose for him because this is what narcissists do ..:o)

BlackAngel: My last relationship was with a narcissist. He was manipulating and controlling, often times without words, just a glance. Is this characteristic of NPDs? It is taking me a long time to regain my sense of self, and nature back. I feel that he drained me dry of everything good in me. Is this a natural feeling to have?

Dr. Vaknin: Yes and yes. Narcissists manipulate because they are control freaks and they are control freaks because they lost control early in life with devastating consequences. They manipulate verbally and behaviourally, and body language is an important weapon in their arsenal of communication. And, yes, your reaction is absolutely normal. You are sad (depressed?). You have gone through the trauma of being a Prisoner Of War. It was war, you know, not a relationship. You were fighting for your life and identity. For your sanity and his. For your relationship as you wanted it to be. So, now you have depression and PTSD. Get help. These two things are treatable, unlike narcissism.

David: I'm wondering how many people in the audience are repeat "victims" of narcissists? I bring this up because we held a conference about sexual abuse dealing with how sexually abused people leave themselves open to further abuse if they don't get professional help. I'm guessing, Dr. Vaknin, that also holds true for victims of narcissists.

Dr. Vaknin: Most victims I know have spent all their life interacting with one narcissist after another. Abused people seem to unconsciously choose abuse in the hope of solving old conflicts and salving old wounds.

SAGUI: Is there any report of a narcissist who, after a life crisis, cured completely?

Dr. Vaknin: Yes, a few in the literature. It was even suggested (1996) that there are two forms of narcissism: transient and permanent. I also think that we should distinguish between: reactive narcissism, narcissistic episode, NPD and narcissistic traits (or overlay).

David: Did the awareness of your Narcissistic Personality Disorder change anything about your "real self"?

Dr. Vaknin: No, I have no access to my real self. I know as much as anyone about narcissism and it helped me none. To heal one must undergo an emotional transformation, to reach the point of the "unbearable being", to want to change fervently. I have only my brain. This is one thing it is not good at: healing. In this sense, I am only a quarter human, an emotional quadriplegic. I had high hopes. I really wanted my brain to conquer my disorder. I studied. I wrote. I read. I fought with the only weapons I had and the only way I knew how. But it was the wrong war. I never got to meet the enemy.

David: It's been a fast two hours. Thank you, Dr. Vaknin for coming and staying so long to answer questions. We appreciate it. And thank you to everyone in the audience for coming and participating. I hope you found it helpful.

Jacqui B: Please, thank Sam on my behalf for his valuable time and care in answering all our questions. Thanks!

vielen: Just wanted to thank you, David and Dr. Vaknin for a very enlightening discussion.

Dr. Vaknin: I want to thank all you for allowing me to talk about this disorder. Thanks for the compliments, the questions - and to the hosts!

SAGUI: It was a pleasure being your Narcissistic supply!!

Dr. Vaknin: LOL

David: Have a good day everyone.

Dr. Vaknin: And from me!

David: Here's the link to the HealthyPlace.com Personality Disorders Community.

You can visit Dr. Vaknin's site, Malignant Self Love and you can purchase his book: Malignant Self Love - Narcissism Revisited.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Online Conference Transcript

Our guest, Dr. Sam Vaknin, has a Ph.D. in philosophy and is the author of the book Malignant Self Love - Narcissism Revisited. We discussed various aspects of narcissism in the workplace, including how to recognize a narcissist, what personality types can work with a narcissist and how to cope with a narcissistic employer.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I hope your day went well. Welcome to HealthyPlace.com and our chat conference on "Narcissism in the Workplace." I'm David Roberts, the moderator of tonight's chat. Some of the topics we'll be discussing include: How to cope with a narcissistic boss, co-worker, supplier, colleague, partner, competitor, manager, or employee. And when is it time to toss in the towel and leave that troublesome job?

Our guest is Dr. Sam Vaknin, author of Malignant Self Love: Narcissism Revisited and an authority on the subject of narcissism. You can read more about Dr. Vaknin by clicking on the link.

Just to clarify, Dr. Vaknin is not a therapist or medical doctor of any sort. However, he is an expert on the subject of narcissism and a self-proclaimed narcissist. Good Evening Dr. Vaknin and welcome to HealthyPlace.com. Just so we are all clear on the subject, can you give us a brief overview of what narcissism is?

Dr. Vaknin: Great to be here again. Thank you for having me and for the kind words. Hello, everyone.

Narcissists are driven by the need to uphold and maintain a false self. They use the False Self to garner narcissistic supply which is any kind of attention adulation, admiration, or even notoriety and infamy.

David: How does one recognize a narcissist?

Dr. Vaknin: It is close to impossible and that is the secret of their astounding success. Narcissists are good actors. They are adept at charming others, persuading them, manipulating them, or otherwise influencing them to do their bidding. The narcissist's sense of self-worth is unstable (labile) so, the narcissist relies on input from other people to regulate his self-esteem and self-confidence. He focuses on potential sources of supply and engulfs them with focused attention and simulated deep emotions. Only in a later encounter, as time passes and the number of interactions grows, is it possible to tell that someone is a narcissist. Narcissists are preoccupied with grandiose fantasies unrealistic plans. They are poor judges of reality. They are bullies and often resort to verbal and emotional abuse. They exploit people and then discard them. They have no empathy and regard their co-workers as mere instruments objects, tools, and sources of adulation, affirmation, or potential benefits.

David: So, in the beginning, you are saying they will get on your good side by charming you and pretending to be interested in you and what you're doing. Later, what kind of behaviors should a person expect from the: (1) narcissistic boss and (2) colleague? And I'm assuming here that the behaviors for the two might be different.

Dr. Vaknin: Workplace narcissists seethe with anger and resentment. The gap between reality and their grandiose flights of fancy (the "grandiosity gap") is so great that they develop persecutory delusions, resentment, and rage. They are also extremely and pathologically envious, seeking to destroy what they perceive to be the sources of their constant frustration: a popular co-worker, a successful boss, a qualified or skilled employee. Narcissists at work crave constant attention and will go to great lengths to secure it - including by "engineering" situations that place them at the center. They are immature, constantly nagging and complaining, finding fault with everyone and everything, Cassandras who constantly predict impending doom. They are intrusive and invasive. They firmly believe in their own omnipotence and omniscience. They feel entitled to special treatment and are convinced that they are above Man-made laws, including the rules of their place of employment. They are very disruptive, poor team members, can rarely collaborate with others without being cantankerous and quarrelsome. They are control freaks and feel the compulsive and irresistible urge to interfere in everything to micromanage and overrule others. All in all, a highly unpleasant experience.

David: If you work with or under a narcissist, it sounds like your work life might be a living hell.

Dr. Vaknin: You would never forget it. It is traumatic and very likely to end in actual bullying and stalking behaviors. Many workers end up with PTSD - Post Traumatic Stress Syndrome. Others quit, or even relocate.

David: What kind of individual, personality-wise, is best suited to work with a narcissist co-worker or boss?

Dr. Vaknin: Certain pathological personalities - for instance, someone with a Dependent Personality Disorder - or an Inverted Narcissist may get along just fine. A submissive person whose expectations are limited, moods are subdued and willingness to absorb abuse is extended would survive with a narcissist, or even thrive in such an environment. But the vast majority of workers are likely to suffer ill-health effects, clash with the narcissist, or end up being sacked, reassigned, relocated, or demoted. The narcissistic bully very often gets his way: He gets promoted, the ideas he "adopted" become corporate policy, his misdeeds are overlooked, his misbehavior tolerated. This is partly because, as I said earlier, narcissists are excellent liars with considerable thespian skills - and partly because no one wants to mess around with a thug, even if his thuggery is limited to words and gestures.

David: We have a lot of audience questions, Dr. Vaknin. Let's get to a few and then I have a few more questions to ask you. Here's the first one:

AMichael: How common is narcissism within the population?

Dr. Vaknin: According to orthodoxy, between 0.7%-1% of the adult population suffer from Narcissistic Personality Disorder. This figure is an underestimate. Pathological narcissism is under-reported because, by definition, few narcissists admit that anything is wrong with them and that they may be the source of the constant problem in their life and the lives of their nearest or dearest. Narcissists resort to therapy only in the wake of a harrowing life crisis. They have alloplastic defenses - they tend to blame the world, their boss, society, God, their spouse for their misfortune and failures. Last, but not least, psychotherapists regard narcissists as "difficult" patients with a "severe" personality disorder - or, put plainly, lots of work with little reward. Narcissists, Paranoiacs and Psychotherapists Narcissistic Personality Disorder (NPD) At a Glance.

Doria57: Is there any way to get along with these type of people at work?

Dr. Vaknin: Here are a few useful guidelines:

1. Never disagree with the narcissist or contradict him.
2. Never offer him any intimacy. You are not his equal and an offer of intimacy insultingly implies that you are.
3. Look awed by whatever attribute matters to him (for instance: by his professional achievements or by his good looks, or by his success with women and so on).
4. Never remind him of life outside his bubble and if you do, connect it somehow to his sense of grandiosity. Do not make any comment, which might directly or indirectly impinge on his self-image, omnipotence, judgment, omniscience, skills, capabilities, professional record, or even omnipresence.
5. Bad sentences start with: "I think you overlooked & made a mistake here & you don't know & do you know & you were not here yesterday so & you cannot & you should, etc. These are perceived as a rude imposition. Narcissists react very badly to restrictions placed on their freedom.

Linda3003: My husband is employed by a very large university, in spite of "outstanding" appraisals, many stolen ideas, marked increase in customer satisfaction and being very professional, he was recently fired. His boss did not like the accolades my husband was receiving, etc. How does one combat the defamation?

Dr. Vaknin: Depends on your resources and your ability to accept recurrent interim defeats. Narcissistic bosses are very tenacious and resourceful. They are pillars of the community, usually widely respected and believed. They have at their disposal the entire wherewithal of the organization. People say "where there's fire, there's smoke". "If he was fired, there must have been a good reason for it", "Why couldn't he simply get along? He must be egocentric, a bad team player." And so on. It is an uphill battle. My advice to you is to team up with an anti-bullying group or to have an attorney look into wrongful dismissal charges.

freedom03: I would like to know if the narcissist is aware of what they are doing?

Dr. Vaknin: Aware, cunning, premeditated, and, sometimes, even enjoying every bit of it. But it is not malice that drives them. They believe in their own destiny, superiority, entitlement, exemption from laws promulgated by mere mortals. The narcissist regards himself as one would an expensive present, a gift to his company, to his family, to his neighbours, to his colleagues, to his country. Resistance calls for strenuous measures. Disagreement with the narcissist is bound to be the outcome of ignorance or obstructionism. Criticism is malevolent and ill-founded. The narcissist trusts that he has the full moral justification to battle his foes. To his mind, the world is a hostile place, full of Lilliputians who seek to shackle his genius, foresight, and natural advantages. They aim to harness and castrate - and they deserve his ire and the ensuing punishment he metes out to them in his infinite wisdom. It is a crusade against the injustice of not recognizing the narcissist's true place in this world - at the pinnacle.

David: Dr. Vaknin, earlier you mention that the narcissist would act empathetic to draw in his prey, so to speak. In light of that, here's the next question:

martha j: Can this person genuinely develop authentic empathy skills?

Dr. Vaknin: No, he cannot. Narcissists lack the basic machinery of putting themselves in other people's shoes. They react with fury and denial when confronted with the fact that persons in their environments are individual entities with their own idiosyncratic and specific needs, preferences, choices, fears, hopes, and expectations. This, the refusal to grant autonomy, is at the core of abuse, whether on the domestic front or at the workplace. To the narcissist, others are mere extensions, instruments of gratification, sources of narcissistic supply. And nothing more than that.

delaware1974: With so many people afflicted with this - why are we making it sound like a death sentence? All of us still need to move on with our lives ...are we supposed to give up and accept because it's hard? We spend a lot of time talking about the negative or "escaping" the narcissist, "surviving" the narcissist, what about those of us that want to help them and NOT give up on them? Are there LIVE face-to-face help groups? Hope?

Dr. Vaknin: It is possible to live with the narcissist, as I made clear earlier. It requires certain behavioral modifications and a willingness to accept the narcissist largely as he is. These may be of interest:

• The Inverted Narcissist - FAQ#66
• Treatment Modailties and Psychotherapies - FAQ #77
• The Reconditioned Narcissist - FAQ#63
• Narcissists, Paranoiacs and Psychotherapists - FAQs#26-27
• Narcissist Employer

David: For many people, Dr. Vaknin, if you are in a situation working with a narcissist or under a narcissist, they can't just pick up and leave their job. What is the best way for them to cope without "kissing" up to this person and being always vigilant about what you say and how you say it? or is that the only way to survive?

Dr. Vaknin: It depends whether the narcissistic bully represents the corporate culture of the workplace - or is an isolated case attributable to a quirky nature or a personality disorder. Alas, very often, abusive behaviors in one's office or shop floor are merely the epitome of all-pervasive wrongdoing which permeates the entire hierarchy, from top management to the bottom rung of employment. Bullies rarely dare to express their tendencies in isolation and in defiance of the prevailing ethos. Or, if they do run against the grain of their place of employment, they lose their jobs. Typically, narcissists join already narcissistic firms and mesh well with a toxic workplace, a poisonous atmosphere, and abusive management. If one is not willing to succumb to the mores and (lack of) ethics of the workplace, there is little one can do. Surprisingly few countries (Sweden, the United Kingdom, to some extent) outlaw workplace abuse specifically. Whistleblowers and "troublemakers" are frowned upon and are not protected by any institutions. It is a dismal landscape. The victim would do well to simply resign and move on, sad as this may be. As awareness of the phenomenon increases and laws take effect, hopefully, this will change and bullied and abused workers will find effective ways to cope with mistreatment.

TimeToFly: What typically happens to a narcissist when they lose their position of authority or their job. How do they react to that? My narcissist ex-husband recently lost his job. He will not say what happened exactly, typical. But since then he has been on a rampage to destroy me. It was right after the loss of his previous job that he left me and our children 4 years ago. He had been the manager of engineering and was first demoted, and then finally left the company. I never did get the story. He has just remarried, but his new life somehow has not distracted him from his obsession with destroying mine.

Dr. Vaknin: Being demoted or losing one's job is a narcissistic injury (or wound). The entire edifice of the Narcissistic Personality Disorder is an elaborate and multi-layered reaction to past narcissistic injuries. A gap opens between the way the narcissistic imagines himself to be (grandiosity) and reality (unemployed, humiliated, discarded, unneeded). The narcissist strives to bridge the grandiosity gap but sometimes it is simply to abysmal to deny or ignore. So, some narcissists go through decompensation - their defense mechanisms crumble. They may even experience brief psychotic episodes. They become dysfunctional. The narcissists redouble their efforts to obtain narcissistic supply by any means - sex, exercise, attention-seeking behaviors. Yet others withdraw altogether to "lick their wounds" (schizoid posture). What is common to all these narcissists is the ominous feeling that they are losing control (and maybe even losing it). In a desparate effort to re-exert control, the narcissist becomes abusive. Sometimes abuse is about controlling the victim. Others seek "easy targets" - lonely women to "conquer" or simple tasks to accomplish, or no-brainers, or to compete against weak opponents with a guaranteed result.

For more on these behaviors:

• What is Abuse?
• The Delusional Way Out
• Deficient Narcissistic Supply - FAQ#28

David: If you are interested in purchasing Dr. Vaknin's excellent and very thorough book on narcissism, Malignant Self Love: Narcissism Revisited, click on the link.

jenmosaic: What causes NPD?

Dr. Vaknin: No one knows. The accepted wisdom is that NPD is tan adaptative reaction to early childhood or early adolescence trauma and abuse. There are many forms of abuse. The more familiar ones - verbal, emotional, psychological, physical, sexual - of course yield psychopathologies. But are far more subtle and more insidious forms of mistreatment. Doting, smothering, ignoring personal boundaries, treating someone as an extension or a wish-fulfillment machine, spoiling, emotional blackmail, an ambience of paranoia or intimidation ("gaslighting") - have as long lasting effects as the "classic" varieties of abuse. Still, there is always the possibility of a hereditary component More about the roots of narcissism here

David: Here are a couple of audience comments about what's been said tonight:

Doria57: No one ever wants to form an anti-bullying group, they are afraid.

martha j: The descriptions of the narcissistic boss --Isn't this the unfortunate all American definition of the "successful" boss?

Dr. Vaknin: I'd like to respond to that last comment. Mental health disorders - and especially personality disorders - are not divorced from the twin contexts of culture and society. Western society and culture are narcissistic. Disparate scholars and thinkers - Christopher Lasch on the one hand and Theodore Millon on the other hand - have concluded as much. Narcissistic behaviors - now labeled "misconduct" - have long been normative. The basically narcissistic traits of individualism competitiveness, unbridled ambition - are the founding stones of certain versions of capitalism. Thus, certain forms of abuse and bullying actually constitute an integral part of the folklore of corporate America. Narcissistic bosses were idolized. As long as this is the case, workplace abuse would be hard to overcome. More here:

• Collective Narcissism
• Narcissistic Leaders

David: Thank you, Dr. Vaknin, for being our guest this evening and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.