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Mental Health Awareness: Out of Sight, Out of Mind

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May is Mental Health Awareness month. It is also set aside as Borderline Personality Disorder Awareness month. As a clinical social worker at Machon Dvir, a Dialectical Behavior Therapy (DBT) clinic in Jerusalem, I have the privilege of working with many individuals diagnosed with Borderline Personality Disorder (BPD). I find them to be among the most intelligent, compassionate, and creative people around. At the same time, they struggle with various obstacles such as emotional dysregulation (experiencing emotions very strongly and have difficulty regulating them), an unstable sense of self, fears of abandonment, impulsive and self-harming behaviors, emptiness, and suicidal thoughts. BPD has characteristically been a very stigmatized diagnosis. I believe this is due to interpersonal challenges that may arise as a result of having fears of abandonment. These fears often lead to fluctuations in relationships, from being clingy to pushing others away because one is scared of getting too close. 

One theory as to why some struggle with fears of abandonment is due to a lack of developing Object Constancy. Object Constancy is the ability to hold on to a closeness and connection with another person even when there is conflict or distance. It stems from the concept of Object Permanence, knowing that people and objects still exist even when you can’t see, touch or hear them. This developmental stage was identified by child psychologist Jean Paiget and usually evolves between four and eight months of age. If you’ve spent time with babies who have yet to develop Object Permanence, you may have noticed that if you hide a toy, they won’t try to look for it, assuming it has disappeared. This is also why babies enjoy playing peekaboo so much.  

Object Constancy develops during a child’s first two years of life if their attachment needs are mostly met.  When a parent responds to a hungry baby or one that needs comforting, the baby learns that the world is a safe place and that they can count on people. The child comes to understand that their parent is a separate individual and learns to hold a sense of that loving figure, even when that figure isn’t there. As a result, the child gains the ability to self-sooth. If his/her needs were not met during those critical years, that person may not feel that same sense of stability and will have a more difficult time coping with challenges in life and in relationships. When there’s a rupture or distance in a relationship, early fears and the pain of being left alone may be triggered, causing regressive behaviors like clinging, demanding, or attacking. Babies experience this as Separation Anxiety, a stage which eventually recedes when a healthy attachment is present.

Individuals who haven’t developed Object Constancy tend to view themselves and others as parts, rather than a whole. It’s difficult to hold on to memories of when someone was there for them, while at the same time they feel hurt or uncared for by that person. As a result, assessments of one’s self and others will tend to change from moment to moment. 

One DBT principle used to address this issue is dialectics, or holding two opposing ideas or realities with both being true. For example, a person may have hurt me AND still care about me. I may not have seen someone for a while AND we can still be connected. Dialectics help counter black and white thinking, which could cause one to believe that a relationship or person is all good or all bad, when in fact, we all have positive and negative traits. We can also apply dialectical thinking to ourselves, acknowledging that we can make a mistake AND be a worthy person.

As treatment approaches advance over time, individuals with BPD are learning how to heal from past hurts and live with the challenges they face. They can begin to recognize when emotions don’t fit the facts of a particular situation and that they may instead be an automatic response stemming from an early developmental trauma. 

The more we can understand Borderline Personality Disorder, the more validating and supportive we can be to those in our lives with BPD. This will, in turn, allow them to become less judgmental towards themselves.

May is Mental Health Awareness Month, and is also International Borderline Personality Disorder (BPD) Awareness Month.  BPD is a mental illness that is characterized by difficulty managing self-image, moods, and behavior. People with this condition experience intense phases of depression, anxiety, and anger that can last from some hours to days.  The month is dedicated to spreading awareness, encouraging people not to hesitate getting help, and ending the stigma that surrounds BPD.

About the Author
Heather Moshel, LCSW, is a Senior Clinician at Machon Dvir, where she provides group and individual therapy, supervises staff therapists, and runs DBT training courses. Prior to making aliyah in 2012, Heather worked with children, adolescents, and adults in New York area clinics and schools. Heather has a masters in social work from Hunter College. She maintains a private practice in RBS in addition to working at Machon Dvir.
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