Originally, I wrote a post about Oppositional Defiant Disorder for this week but in light of my horrific day, I’ve decided to switch gears and write about what working in community mental health is like as a professional.
Community mental health is a branch of mental health at works with clients in an outpatient or community setting. This includes your standard counselors, community-based programs, psychosocial rehabilitation, in-home services, and many more. Basically, if it’s not in-patient, it’s community mental health.
Let me begin my sharing my transition of positions over time. I was initially hired at my current company to provide Mental Health Skill-Building Services. After about 3 months, I transitioned to providing Crisis Stabilization Services. Both of those positions were working directly with clients in the community and the primary support of my post today. Read more
September 5th-11th is National Suicide Prevention Week here in the United States. In recent years it has been advertised more heavily, though I still primarily see advertisements directed at mental health professionals rather than the general public. I find this odd because most mental health professionals have some knowledge of the signs and statistics while many people in the general public do not.
Suicide is an often taboo subject in our current culture. It is rare someone openly discusses this epidemic and I believe this leads to a reduction in people recognizing signs and seeking help. Most all of the clients I work with have a history of at least suicidal thoughts, if not suicide attempts. The reality is that talking about suicide is important. Read more
A woman sits in my office, crying, after she finishes telling me her story. She’s had a hard life full of mental health issues and substance abuse. When she finishes her story, she wipes her eyes and looks at me. Then she asks me the most dreaded question in counseling: “What’s wrong with me?”
How would you answer that question? Read more
Mindfulness is the practice of being intentional, being reflective, and living in the moment. There are innumerable ways to be mindful and individuals with mental health disorders can benefit from mindfulness and positive ways to cope with their symptoms. Mindfulness is particularly helpful to people with Borderline Personality Disorder and anxiety disorders. Read more
I’m finally about halfway through with my residency and about halfway to becoming a Licensed Marriage and Family Therapist (LMFT) in Virginia. When I’m mentioned this before, I’ve gotten a lot of feedback about people being surprised at how much was involved in becoming a licensed therapist. Today I’m going to dive into the requirements for Virginia LMFTs and my journey. Read more
Dissociative Identity Disorder (abbreviated DID) is a unique and intense psychological disorder. While this has previously been called Multiple Personality Disorder, DID is not a true personality disorder due to the nature of its dissociative symptoms. Dissociation means separation or breaking. With DID, this is the separation is a separation of self or identity. Read more
I’ve gotten some amazing feedback from you guys after some recent personality disorder posts I’ve written. As a result, I’ve put together an email course with more information about personality disorders!
I’ve written and assembled this course to provide information for educational purposes only. This information is not designed to diagnose, treat, or cure any mental illness. This course’s purpose is to provide you with information about personality disorders and encourage you to seek a professional in your area if you believe you or someone you care about may have a personality disorder.
I’ve included some common terms and definitions, different ways personality disorders are grouped, and bonus material! In addition, I’ve written 10 posts worth of information about different personality disorders that I’ve included in this course. You’ll also receive awesome extras with more information about all the current DSM personality disorders! Read more
Antisocial Personality Disorder (abbreviated ASPD) is another commonly misunderstood diagnosis. Like other personality disorders, people with ASPD cannot control their symptoms however people with ASPD are often seen as in control of their symptoms.
Let’s talk about Narcissistic Personality Disorder (abbreviated NPD). Unlike Borderline Personality Disorder, it is often easier to recognize NPD in others due to the more “obvious” pattern of symptoms. Like other personality disorders, people with NPD cannot control their symptoms. While you will likely be put off mb their behavior, remind yourself that it is beyond their control.
Clarification: People you might label as “conceited” or “full of themselves” do not necessarily have NPD.
Behind The Name
Narcissistic Personality Disorder gets the name from the Greek myth of Narcissus. Narcissus was a beautiful man who believed no one was worthy of his love, refusing the advances of others. He refused the advances of a nymph named Echo, causing the god Nemesis to seek revenge on Narcissus for his selfish and inconsiderate behavior. Nemesis lured him to a pool of water where Narcissus saw his own reflection and instantly fell in love with himself. Narcissus stayed by the pool for days, trapped in his infatuation. Eventually, Narcissus committed suicide when he realized his reflection could never return his love.
Why is this story important? This story basically summarizes the criteria for Narcissistic Personality Disorder.
In order to be diagnosed with any personality disorder, you must meet criteria for both a general personality disorder, as well as the criteria for the specific personality disorder.
General Personality Disorder Criteria
Unlike other mental health disorders, personality disorders all have the same core criteria. There are 5 core criteria that must be met, as well as criteria for the specific personality disorder. The 5 core criteria are:
Significant impairments, problems with self-identity or self-direction, as well as interpersonal functioning (think intimacy or ability to empathize)
One or more pathological (“bad”) personality trait (detachment from others, disinhibition, antagonism, psychoticism, or negative affectivity)
The same impairments are relatively stable across situations and time
The impairments are not better explained by the normal developmental stage or the culture of the person
The impairments are not due specifically to drugs or another medical condition (such as trauma to the head)
Narcissistic Personality Disorder Criteria
To be diagnosed with Narcissistic Personality Disorder, you must have a continuous pattern of real or fantasized grandiosity (exaggerated belief of self-importance), a need for admiration, and a lack of empathy. This must also begin by early adulthood and must be present in across situations (church, home, work, etc.).
In addition, you must have 5 of the following:
1. Inflated sense of self-importance
Exaggerates achievements or talents, or expects superior recognition without necessary work or achievements
2. Preoccupation with fantasies of unlimited success, power, intellect, beauty, or ideal love
3. Belief that they are special or unique and can only be associated with, or understood by, high-status people
4. Requires excessive admiration
5. Has a sense of entitlement
6. Exploits others to meet their own needs or goals
7. Lacks empathy
Either does not recognize or acknowledge others’ feelings
8. Is often jealous of others and believes others are jealous of them
9. Shows arrogance, elitist behaviors and attitudes
People with NPD often have fragile self-esteem, easily injured by criticisms and critiques. People with NPD will often change their opinion of others if they do not meet their desires of continuous praise. This may take the form of direct conflict with the person or degrading the person later.
Relationships are often one-sided due to a lack of empathy. People with NPD often make inappropriate and hurtful statements to others, such as boasting about a new relationship in front of their former lover or brag about exceptional health in front of a chronically ill person.
There is no definitive cause for Narcissistic Personality Disorder. The primary theory of cause is the relationship a child has with their parents: excessive praise (“putting them on a pedestal”) and excessive criticism of the child have both been linked to NPD.
Medications are rarely effective in treating personality disorders.
I have previously mentioned Dialectical Behavioral Therapy, or DBT, as a treatment model for Borderline Personality Disorder. This model of therapy has been adapted for NPD.
In addition, individual and family therapy can be beneficial to both the individual and those close to them.
Finally, it is incredibly important for the supports of a person with NPD to educate themselves about Narcissistic Personality Disorder.
Narcissistic Personality Disorder is significantly more common in men than women. 50-75% of people diagnosed with NPD are male.
People with Narcissistic Personality Disorder often struggle with aging and increased limitations to completing tasks.
0-6.2% of the U.S. adult population has NPD, according to random samples throughout the country.
People with Narcissistic Personality Disorder often have more than one mental health diagnosis.
Most common are substance abuse disorders, mood disorders, PTSD, and other personality disorders.
Narcissistic Personality Disorder is often not diagnosed until adulthood due to the normal presence of several of these traits during adolescence.
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My mother has Borderline Personality Disorder. If you are unfamiliar with Borderline Personality Disorder, start here. For those of you with a relative, or even parent, with BPD, you know how exhausting this situation can be to endure. While many people have been formally diagnosed before they realize they have a personality disorder, my mother has never been formally diagnosed by an outside professional.
I am the one that diagnosed her. I realized her diagnosis when I was in graduate school working in my internship with people with addictions and co-occurring disorders. More on that later.
Like anyone else with a mental illness, she has good days and bad days. I’ve come to think of my mother as two different people: my real mother and the borderline version that controls her. On good days, my real mother is there, pleasant and fun. On bad days, which are unfortunately the norm, my borderline mother is there, arguing and trying to bully me into spending time with her.
Word of Warning: If you suspect someone you love has Borderline Personality Disorder, refer them to a professional to be assessed and educated. It is often an incredibly difficult conversation to tell someone about their diagnosis. There will be a backlash and it will be ugly.
I’m going to walk you through my experience growing up with a parent with Borderline Personality Disorder. Be prepared, it is LONG. I wrote it over several days and I had to write this post from present to childhood.
Notes About My Mother
My mother’s default weapon is guilt (this is not true for every BPD parent)
I am her only child, and I was born on Christmas. She basically holds my birthday/Christmas hostage, complete with overwhelming guilt.
She had an incredibly close, positive relationship with her mother
She didn’t display many BPD traits until her mother died
My mother and father work at the college I attended
My mother didn’t display many borderline traits when I was very young and few directed at me. She did have an overwhelming ability to make me feel guilty for the stupidest things or would regularly say “I love you but right now I don’t like you.” I mostly saw her traits when she interacted with people outside of the family (rapid changes in relationships, paranoia).
This lasted until my grandmother died. My theory with this is that my grandmother could help her regulate everything in her life and after my grandmother committed the ultimate abandonment act (dying), she didn’t know how to handle her life anymore. Then her symptoms really started showing.
Once my grandmother died, my entire family shifted. We had a lot of overall shifting but one of the biggest shifts was the emergence of my mother’s borderline traits. After the catastrophic aftermath settled, I noticed some significant changes. My mother was hyper-focused on me.
She started interfering in my relationship with my dad, preventing us from spending quality time together. Showing any interest in this relationship meant I didn’t care about her.
During high school, she looked through my files on the computer, listened to my phone conversations, barged into my relationships, and essentially refused to allow me to have any sense of independence. Her overwhelming fear of abandonment overshadowed her parental ideal of fostering independence. I thought she was going to lose her mind when I opened up a bank account by myself.
I also noticed she didn’t have any friends. Literally zero friends. And she tried to use my friends to help her develop some sense of self-identity. Being my mother was her entire identity and she needed my friends to see how incredible she was to help better develop her sense of self.
This pattern of overbearing, controlling, crazy-making behavior continued until I finally graduated and left for college.
Once I was finally able to move into my dorm, I felt free. I no longer had to answer to anyone, fear someone barging in on my safe space, or worry someone was looking through my stuff. I could expect relative consistency from the people around me and I thrived.
Around the 3rd week of school, my mom started this awesome habit of calling me at 6:00PM on Fridays. I’m assuming this was her attempt at preventing me from partying (which she really didn’t need to worry about). She would try to keep me on the phone for hours, talking about nonsense. She’d also use this time to attempt to guilt me into visiting her on campus several times per week. This pattern continued until my second semester when I finally agreed to meet her once a week for lunch, within a time limit (because I was a full-time student with 2 part-time jobs). I also primarily stopped answering her Friday night phone calls.
In her defense, I had really started to avoid her so her noticeable pushback for attention drove me extra crazy. And she hated my boyfriend at the time so I wasn’t thrilled to hear about that every time we talked.
The first year went well overall after she finally adjusted to the fact that I didn’t live with her anymore. Looking back, I realize this was an incredible struggle for her because being my mother was her only identity prior to my leaving. For someone with a disorder characterized by unstable image, that’s like pulling out the bottom block in Jenga.
After she got over the loss of her long-term identity (“mother”), she started developing really intense friendships with other women on campus. She got really involved in Pogo.com games and chatted with a ton of people on there. Somewhere in there she started emotionally cheating on my dad (likely still going on).
During my second winter break, my then boyfriend (now husband) invited me to Christmas with his dad’s family. I was so excited to get invited and I happily agreed. To my mother, it was the same as stabbing her. To her, my actions didn’t say “I want to spend part of my birthday here and part there.” They said, “I hate you and I never want to see you again!” She still hasn’t let me forget this heinous crime.
When I decided to work at a rafting company the following summer, it was like I twisted the knife from Christmas. She was very upset that I wouldn’t be home all summer and I wouldn’t be spending time with her (despite the opportunity to live rent-free and work full-time). She never came to visit me that summer.
The next fall I used my saved money to buy a new car. I had been driving their unreliable-at-best minivan until now. I was pretty convinced my mother thought I was trying to kill her. She repeated nagged me about how I should keep driving their van on their insurance, how I wouldn’t get an insurance discount as good as what we had now, and how she wanted my dad to look at the car. In reality, I was about to get rid of her last big area of control over me. I’m certain she had some normal parent concerns but for the most part, it felt like a control issue.
Then it came time for me to apply to graduate school. She was her normal, negative self until I needed to conduct interviews. She offered to drive me to the closest interview (3 hours away) and I happily accepted. Leading up to that day, we have a pleasant relationship. When she picked me up that morning, it went downhill. She criticized my outfit for about 30 minutes then later informed me we would be stopping to see her old friend. I obviously couldn’t say no since I had no other way home. She had tricked me into spending more time with her. At the interview, she walked me to the room and waited outside (even after I asked her not to).
Later that month, I flew out to Oregon to do another interview. She knew I had applied to a variety of schools but she was very opposed to Oregon. I know normal parents aren’t thrilled at the idea of their children moving across the country but I’m fairly certain most of them either get over it or adequately express their feelings. My mother is not a normal parent. She lacks the ability to express her real emotions, instead making guilt-ridden statements such as “What if something happens to me or your dad?”
I ultimately did not get into the schools across the country and accepted my place at Appalachian State University. The summer before I started, I returned to the rafting company in West Virginia and my then boyfriend proposed. I didn’t tell anyone until I drove down to see my mother. When I told her, not only was she not excited, she got mad at me and didn’t believe me when I said she was the first person I told (she then spent the next 4 years leading up the wedding telling me he had to get her’s and my dad’s approval before I could get married). I pretty much ignored her for the rest of the summer.
Naturally, when it came time for me to move, my mother was a little frantic. Not only have I worked out-of-state all summer (different state), now I was moving to another state for at least 2 years. You can imagine she felt abandoned. Here I was, her only child, moving 3 hours away for graduate school.
Contrary to the typical overbearing parent, she rarely called. Often, she would make me feel guilty when I called to check up on her, saying things like “I was wondering when you’d call. I haven’t talked to you in 3 weeks.” She would occasionally drive to see me and we would have an uncomfortable and tension-filled meal. Then she would leave, later trying to make me feel guilty for never coming home when she would drive 6 hours in a day to see me (she knew I couldn’t afford it).
This pattern of feeling betrayed is typically in people with BPD. They often report feeling disrespected and abandoned when they do something for someone else and the other person doesn’t reciprocate.
I started to suspect my mother of Borderline Personality Disorder during my second semester Diagnosing and Assessing class. One thing I learned about people with BPD was their behaviors typically worked for them to meet their needs at one point in their life and now those behaviors don’t work, often causing the opposite reaction.
I also learned that most people with BPD have a history of trauma. The same is true for my mother. I used a school assignment of creating a genogram (family tree + relationships and family patterns) to get a better understanding of her history. Her mother was abused by her father and they later divorced. She also talked about her sister being violent towards her.
In a therapy program, you learn a lot about how to help and support others. What’s rarely talked about is how much you learn about yourself.
I came to the realization that my mother has Borderline Personality Disorder when I started working with Meg (named changed) in my internship. Meg had many of the classic symptoms of BPD: frequent & severe mood changes, unstable relationships, and an intolerance for being alone. The longer I worked with her, the more she reminded me of my mother.
One day when I was reviewing the criteria for BPD, I realized my mother met almost everysinglecriterion. She wasn’t acting like this on purpose – she has a personality disorder! This moment was revolutionary for me because it started my process of not taking her actions personally. I have to continually remind myself of this when she attempts to manipulate me through emotional blackmail.
Once I realized her diagnosis, I tried very hard to let go of the years of anger I had built up. My view of her changed from “my crazy, overbearing mother” to a long-standing victim of her past. It also allowed me to start looking at my own learned borderline behaviors and change them.
Note: Children of people with mental illness can learn behaviors associated with those mental illnesses even though they may not have them.
I’m still struggling in my relationship with my mother. I have a lot of anger towards her and towards the universe. In my adolescence, I accepted that I would never be best friends with my mother. I’ve transitioned to anger at the universe for taking away any chance I could have ever had at this type of relationship with her.
She continues to intervene in mine and my dad’s relationship. My dad never got a cell phone so any time I need to get in touch with him, I have to go through her.
I’m still not great at setting boundaries but I’m so much better than I used to be when I first started setting them. What’s more, I’ve gotten better at maintaining boundaries with her.
She continues to struggle both with understanding and following these boundaries. Here’s a recent example for December:
I volunteered to help my young cousins one weekend in December. I later got an invitation from my family to our annual family gathering which happened to be the same weekend. I let me my mother (via text) know I couldn’t make it because I’d already agreed to babysit that weekend. She quickly responded asking if I could bring them to the event. Before I could respond explaining the situation (i.e. I’d be out-of-state at their house), she began calling me. I didn’t answer her because I knew she was heightened and it was a situation I didn’t want to put myself in. It turns out she was very heightened. She called me 57 times without leaving a message or taking a break. I wasn’t even able to finish my text to her for over an hour because of this.
I rarely try to explain other people’s behaviors however I must make an exception for this. This is an example of one of the core diagnostic criteria for BPD: frantic efforts to avoid real or imagined abandonment.
I can tell you from decades of experience that not answering a call from my mother only means 1 of 3 things to her:
I’m avoiding her
I hate her
Despite years of repeatedly telling her my phone was on silent or I was unavailable, she continues to jump to these conclusions. I can’t blame her, however, because it is literally part of her personality.
Borderline Criteria & My Mother
1. Frantic efforts (wild, chaotic, disorganized) to avoid real or imagined abandonment (does not include suicidal or self-harming behavior)
This is basically the rule my mother lives her life by. She also experiences paranoia related to her fear of abandonment (#9). 2. Pattern of intense, unstable relationships that frequently shift between extremes
My mother has only had one stable relationship in her life, and that relationship was with her deceased mother. She often changes from love to hate with me, my dad, other family members, friends, co-workers, and acquaintances. 3. Identity disturbance, such as ever-changing/unstable sense of self or self-image (Often presents as rapid career changes, sexual identity, morality, or types of friends)
My mother changes friends quickly, changes her mind on moral issues quickly, and has changed jobs approximately 12 times in my lifetime. 4. Impulsivity in at least 2 self-damaging areas (sex, spending, reckless driving, substance abuse, binge eating, etc.)
My mother has a history of reckless driving, binge eating, and emotional/impulsive spending. Despite being continually late or overdue on the mortgage AND cell phone bill, she bought a new chest freezer. Then 2 years later, with the same financial situation, she bought a dishwasher. 5. Recurrent suicidal behavior, gestures, or threats, OR self-harm
She does not do this. 6. Inability to control or cope with moods (extreme reactions, usually lasting anywhere from a few hours up to a few days)
Every reaction my mother has is extreme and she takes everything personally. For example, she responded to my engagement announcement with anger and disrespect. 7. Chronic feelings of emptiness
She has not expressed this, though she was diagnosed with “Empty Nest Syndrome” and later Major Depressive Disorder. 8. Inappropriate, intense anger or difficulty controlling anger
My mother has no ability to control her anger, which is often out of proportion with the situation or completely uncalled for. She often gets angry and is unable to explain the cause of her anger. She will also suddenly get angry about something that occurred months or even years ago. 9. Fleeting stress-related paranoid thinking or severe dissociative symptoms
My mother has paranoid thinking about abandonment and what others think of her. She has never talked about any type of dissociative symptom.
How I Cope
It’s been about 3 years since I realized my mother has borderline personality disorder. Since I realized this, I’ve spent a lot of time reflecting on my childhood and adolescence, and working through years of anger. I haven’t formally gone to therapy for this, though I need to. I talk about how this relationship impacts my life and my work every week when I meet with my supervisors (for mental health licensure, not direct supervisors).
The things I’ve found to be most helpful are trying not to take her statements personally. When she tries to make me feel guilty, I focus on how she’s trying to communicate another message, like “I want to spend more time with you.” It takes a lot of reminding.
I also try to focus on the good days, when my real mother is there.
I intentionally avoid playing her games and fighting fire with fire. If she begins to act passive-aggressive, I simply say what I think the issue is.
I have to set a lot of boundaries, such as “I feel like you’re only trying to make me feel bad so I’m getting off the phone.” or “You cannot stop by my house with letting me know in advance.”
I also have to be assertive, something I did not have growing up. This is when I say things like “It’s not okay to talk to me like that.”
And I talk about it, a lot. I talk to my best friend, my supervisors, my husband; anyone that’s appropriate. I write about it because it helps get the years of anxiety, frustration, fear, and anger out.
And I read everything I think could be helpful to me.
I used to think my family was pretty normal until I went to grad school and realized it was just a shitshow I’d adjusted to. I hope you enjoyed my story.
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