Interview of Mr Randy Wolbert Nsw granted on november 19th 2002

Q: Could you first of all talk a little about you and your experience in mental health research and / or in the BPD treatment?
I have treated BPD within the context of a community mental health setting for 23 years.  I have been effectively using DBT for the last 7

In a few words very simple to everyone (not DSM)
Q: "What is the Borderline personality disorder ?"
A pervasive dysregulation of emotions leading to impulsive behaviors

Q: Is it a "woman illness" ?
(question not asked)

Q: What differentiates it from other diseases and personality disorders?
A different set of behaviors

Q: A lot of specialist suggest that the "childish" side of the adult borderline totally essential in the illness? (including Black and White thinking - All good - All bad - No middle)
If you mean impulsive by childish - yes it is a defining characteristic

Q: Same comment about the sudden rage ?
Intense anger is one of the 9 symptoms listed by the DSM-IV for BPD

Q: How to be sure that it is borderline disorder and not another mental illness ?

By carefully exploring symptoms and comparing them to the established norms

Q: Do you think that brain imaging can help to an accurate diagnosis for BPD ?
(question not asked)

When we are in the circle of one person potentially borderline.
Q: What are the behaviors, the alert signs to tell "this time it is not normal, it would be necessary to him/her to consult a therapist"
Any set of behaviors that leads to significant social and/or occupational functioning should be considered a target of treatment - basically all of at some point in our life have engaged in similar behaviors to individuals with BPD - it is a question of intensity and pervasiveness - if your behavior continually causes you to loose friends, or your job, engage in suicidal or other risky behaviors it is time to get help.

Q: At which age can we start to see the first signs and worry about ?
Varies widely by individuals most show up in the mental health system by high school but not uncommon to be earlier or later - I have treated individuals as young as 13.

The people having this disorder "used to be" like this from all their life and it is "the way they are"
Q: why in that case don't leave them and let them continuing to live their life ?
Because they are usually very miserable and often suicidal and if treatment is available it is the humane thing to do

Q: Are borderlines patients more "fragile" and subject to "somatization" ?
lot of small illnesses, some somatics illnesses (dermatological, ORL, ...)
(question not asked)

Precisely about this illness
Q: "is there a cure ?"
DBT has been shown to be effective at reducing and often eliminating the behaviors that comprise BPD


Q: Is using medication (almost during a time) necessary or a "simple" therapy can be enough ?
Medication can be a helpful adjunct to treat specific Sxs but real change only occurs through therapy

Q: Same question but only medication without therapy
There is no evidence that medication without therapy is effective

Q: Is that mean that only a psychiatrist therapist doctor is able to cure a borderline patient ?
Best treatment results have been obtained by DBT trained therapists - which could include psychiatrists, psychologists, social workers and nurse practitioners - for instance I am a social worker.

Again about médication: Selective Serotonin Reuptake Inhibitors (5 hydroxytryptamine) seems to be very important. A lot lot of patients (and studies) are talking about Fluoxetine as a "miracle drug".
Q: What is your opinion ?
(question not asked)

Q: We talk about "low functionning" borderlines (cut, suicidal) and "high functionning" patients (seems "normals").
Do you believe in this ? (two illnesses)
(question not asked)

There seems to be a debate. First of all a "truth" seems to be that "classical standard therapy don't work with borderline peoples" right ?
(question not asked)

We have read that DBT therapy "Dialectical Behavioral Therapy" is accurate (working)
Q: Your opinion ?
(question not asked)

We have read that all of this doesn't work with "high functioning" borderline. To be clear they are hopeless, condemned to suffer all their life
Q: not really optimistic no ?
(question not asked)

Really a disease

Q: Is the word "Borderline" suitable, borderline means "not really"
The term borderline is left over from psychoanalytic days - meaning walking the border between psychosis and neurosis - a better descriptor would be pervasive emotion dysregulation disorder (perhaps in the DSM-V)

In France, some peoples, and even psychiatrist are saying, "we are all borderline", to be clear that this illness doesn't exist
Q: what is your opinion about this point of view ?
We all have the capability of acting this way usually when we are emotionally vulnerable and are feeling invalidated - however the criteria for BPD is quite specific and really only 1-2% of the population seem to meet criteria.  Often because of the stigma there is reluctance to give this diagnosis. However with an effective treatment such as DBT it is better to diagnose correctly to assure that the correct treatment will be applied.

Q: About DSM IV. A lot of therapist in France when we say "DSM" have some "disdain", like it was "useless"
Could you answer this ?
(question not asked)

The answer is certainly not but I ask
Q: Is each / every psychiatrist has the training and experience to treat borderline patient ?

Q: Do you think that there is actually some deficiency in this domain ? (training and education of mental health providers)

In France, mental illness is a taboo like cancer was some years ago
In everybody mind, someone going to consult a psychiatrist is "mad" or "retarded"
Q: what could you say about this ?
Not much different in this country - it is why it is so very important to have advocacy groups and to provide education - when you add together all the mental illnesses you will find that most families are affected in some way - it is a shame that we can talk about it more

About this subject, we often associate the "cure" with the "willing" to
"Please stop to do, acting like this and do what it is necessary !"
A kind of "if you want, you can" and "if you are not doing, that's mean that you don't want"
Q: what is your opinion ?
Without teaching individuals the necessary skills we can;t expect them to stop the behaviors that have been effective in regulating their moods over the years - it is often not a question of wanting to stop - they all want to stop - it is more of a question of learning how to regulate their emotions in other ways - which is what DBT is about

Q: What do you think about the idea to create an association to promote knowledge of this illness and help peoples ?
I am all for it - As I mentioned earlier there is an organization in the US known as TARA (Treatment and research advancement) there is also the National Alliance for the Mentally Ill (NAMI) - I very much recommend getting in touch with Valerie Porr

It is ethically very difficult to force something to be treated (I suppose that it is also useless if he don't want)
But we know that all over the world there are thousands of sick peoples, which don't know that they are sick, and thinking that it is the "way they are" to suffer
Q: What do you think about the principle of "diagnosis obligation" when we are in contact with someone potentially Bpd (or other mental illness), to "force" him / her (i don't know how) to see a therapist, not to treat him (her), but only to give him (her) an accurate diagnosis ?
In that way it would be more difficult to him (her) to say "i'm not sick" (and also to the family circle to believe the lyings)
The second point is that perhaps it could help him (her) to become aware that he (she) is sick
So ?
I think as a human being I have an obligation to eliminate suffering as best I can

(Only if you think that it is not a good idea)
Q: In that case, don't you think that there is an high risk for the borderline patient to think
"I suffer, I know, but I'm unique, it's my nature" and not thinking "I'm not alone like this, I'm just sick" and then never be treated ?
(question not asked)

Question without answer I suppose
Q: "how to convince the patient to consult a specialist ?"
DBT has a whole set of what we call commitment strategies - the first step is to try and let the individual know that there is help for the misery that they are experiencing

I suppose that it is hardly more difficult to convince an high functioning borderline to consult a therapist (if they are saying "i have nothing")
Q: Once again what is your experience, the solution ?
(question not asked)

The BP Distortion Campaign
"When a BP deliberately tries to convince others that the Non (the one who know) is the one who is sick"
Q: is it a common data ?
When feeling defensive most anyone will turn on someone they feel is attacking them

Q: how to manage this ?
State a willingness to go with them to see someone who can help sort things out

Q: More generally, how to "manage" relationships with a borderline ?
(question not asked)

The borderline seems to have a childish emotional IQ
Q: Is it "sensible" to ask a "children like" to take such a decision ?
(consult or not, treat or not)
Even children are able to make reasonable wise decisions at times - It has been my experience that they really do want to improve and that they are doing the best they can.

Q: Is it not totally utopian and even cruel to ask them taking such a decision ?
No - ultimately they may not have caused all their own problems but still have to take the responsibility to solve them

Q: What is your experience about this ?
How borderline people "come to you" ?
Usually when I first see them - they have been recently in a psychiatric hospital and don't want to go back and are interested in getting help.

Origin of the disease

The origin of the illness seems to be really complicated when we talk about borderline disorder, but it seems that trauma during early age are the main reason
Q: What do you think about this?
I believe that BPD is a transaction between emotion vulnerability (biology) and an invalidating environment - both elements are necessary - that being said there is a high incidence of sexual and/or physical abuse among patients with BPD but abuse does not account for all cases nor do all those you have been abused develop BPD

Q: Could Childhood Epilepsy Cause the BPD ?
(question not asked)

Q: Opposite question. Could Bpd cause epilepsy ?
(question not asked)

Q: This illness could have genetic and / or biologic origin, what is your opinion ?
(question not asked)

The family could be a great help to support the patient.
But when one of the parents has some part of "responsibility" (even not conscious) in the illness of her own children,
Q : How is it conceivable for this parent to open yes about the reality of the situation ?
If all are willing we do family therapy in which e teach family members skills as well.  Just like we assume that our patients want to improve and are doing the best  that they can we make the same assumptions about families

It seems that mental illness is passed down through generations like a child of an alcoholic would become alcoholic at the adult age
Q: Is it true ?
Yes there is a strong genetic component

Q: Is it the same with borderline disorder ?
The borderline mother is going to make her daughter borderline ?
There is evidence that many patients with BPD come from families that have affective disorders such as depression or bipolar disorder (or BPD)

Q: How to break this infernal circle ?
Not if the mother receives adequate treatment

Latest questions
Q: Is there one question you would like to answer and I didn't ask ?

Q: Is the last word "hope" ?
There is an effective treatment available - I hope you get an opportunity to contact TARA and the Behavioral Technology Transfer Group to find out more about this treatment and how to bring it to France

Questions answered with the kindness of Mr Randy Wolbert. - MSW Clinical Director
InterAct of Michigan

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