Podcast: How to Help Folks with Borderline Personality Disorder Who May Refuse Treatment

Guest Bio

Dr. Connell Cowan (Los Angeles, CA) is a clinical psychologist. He co-wrote Smart Women/Foolish Choices, a runaway bestseller that spawned an entire genre of books dealing with male/female dilemmas. The book spent nearly a year on the New York Times bestseller list, sold millions of copies, has been published in 23 different languages, and was made into a hit musical. His second book, Women Men Love/Women Men Leave, also became a NYT bestseller. Husbands & Wives completed the relationship trio. He has appeared on hundreds of radio and television shows and his writings have been published in a number of journals, magazines, and newspapers internationally. Dr. Cowan also established the Human Sciences Center in Los Angeles––a nonprofit center for research and treatment funded in part by a grant from the Eli Lilly Foundation. The innovative work he developed at the Center was featured on CBS’s “60 Minutes.” He has taught at the California School of Professional Psychology and in UCLA’s School of Public Health. Along with his writings and clinical practice, Dr. Cowan has created and produced a number of television and video projects for syndication and cable blending both psychological information and drama.

His new book, Override: Discover Your Brain Type, Why You Do What You Do, How to Do It Better,is written in with Dr. David Kipper. It’s based on breakthrough science and reveals the blueprint of our DNA and gives readers a practical, easy-to-grasp, yet revolutionary framework to go beyond survival and toward achieving the life you really want.

Inside Mental Health Podcast Host

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without.

To book Gabe for your next event or learn more about him, please visit gabehoward.com.

Computer Generated Episode Transcript

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Greetings, everyone. I’m your host, Gabe Howard, and calling into the show today, we have Dr. Connell Cowan. Dr. Cowan is a clinical psychologist and author of the 1986 New York Times best-selling book “Smart Women/Foolish Choices.” Dr. Cowan also established the Human Services Center in Los Angeles, a nonprofit center for research and treatment that has been featured on CBS’s 60 Minutes. Dr. Cowan, welcome to the show.

Dr. Connell Cowan: Thank you very much, Gabe. I’m happy to be here.

Gabe Howard: I want to start off by saying that even in mental health circles, borderline personality disorder is very stigmatized. It’s a topic that we covered in the episode, Stigma of Borderline Personality Disorder with Dr. James Seymour. One of the reasons that this stigma seems to hold is because people with borderline personality disorder often refuse treatment, leading their friends and family members to assume that this illness is their fault. But is that a fair and reasonable thing to believe?

Dr. Connell Cowan: No, I don’t. I don’t think that’s fair or reasonable. First of all, borderline personality disorder is a terrible kind of diagnostic label to have. Part of the reason it’s a such a bad label is that it’s very nonspecific. It’s often comorbid with so many other things that it’s a catchall, um, kind of diagnostic label. I mean, first of all, when you hear borderline, the what comes to the mind of a lot of people is it’s kind of the borderline between sane and insane. And people with this kind of diagnosis are not crazy. They’re just hurting. And there are reasons that they don’t seem to get into treatment at the same rate that some other people do. And I think the primary reason is that they don’t see themselves at the at the center of their problem. The way they’ve built up protective mechanisms for themselves is to externalize the reasons for what they see happening around them as opposed to feeling at the center of them.

Dr. Connell Cowan: And in working with the borderline person, that’s really the function of the work is to create self-awareness and the awareness that that that they control their life, they control what happens around them because they don’t feel in control. They feel at effect of it all. And when you are feeling at effect, you don’t see yourself as the reason for the events that swirl around and because you don’t you know, therapy just doesn’t seem like it’s going to be of help. And look, a lot of times borderline people have big swings, big emotional swings. So sometimes they’re feeling very confident. When they’re feeling confident, you know, therapy is the last thing that occurs to them. And then when they’re feeling really down and empty, which is another kind of very common feeling for borderline people, they feel hopeless and like therapy couldn’t possibly be of help. So, there are a lot of reasons that they don’t want to get into therapy, even though therapy can be helpful.

Gabe Howard: In preparation for this episode, I did a simple, nonscientific poll of people who identify as living with borderline personality disorder, and I asked those who refused treatment why? And the top two reasons that they gave were because, one, they think that the treatments won’t work, or two, because they feel stigmatized by medical professionals. And many people indicated a combination of both. How can we address this?

Dr. Connell Cowan: Well, I think the stigma issue is. Is being addressed over time. Things are changing and they’re changing slowly. But it’s, it’s not the kind of stigma that people think it is. I think we’re moving in the right direction. Are we there yet? No, we’re not. Um, so the other thing is they don’t think that it would be helpful. You know, I think part of the issue is if you don’t try something, um, you have no way of knowing. I mean, you know, we make a lot of assumptions. We, we jump to conclusions. You know, it’s interesting. We don’t have a phrase that jumps away from conclusions. We only jump to them. So, conclusions are really easy to jump to and much harder to kind of get away from. But the notion of disappointment, I think particularly for people who identify with these borderline kinds of symptoms is a sensitive issue. Trust is a sensitive issue. If you’re thinking of getting into treatment there. That’s those are big issues. Rejection. The fear of rejection is a big issue, uh, so that there’s a lot of emotional resistance to doing that. Uh, people who identify with borderline kinds of symptoms very often are disappointed in people. I mean, a one of the most classic dynamic in a relationship with someone who is struggling with these issues is that initially they think you can do no harm.

Dr. Connell Cowan: They idealize you and then inevitably, you make a mistake, your disappointment, disappoint them in some way and you become their worst enemy. And so, they have a long history of being disappointed and in in those kind of important relationships. And, you know, if you’re going to sit down and talk to someone, you’re vulnerable. You are open to being hurt. You’re open to being disappointed. And they have a history of that and they don’t want to repeat it. So, there are a lot of reasons why they don’t want to get into therapy. But what I what I try and get people to do is to just give it a try. And very often if they give it a try, they actually can connect. But, you know, it’s interesting. If you’re looking just at the diagnosis, the remission rates for people with borderline issues are really remarkable. Unlike other personality disorders which are very stable, I mean, people who are antisocial aren’t just antisocial for a while. People who are narcissistic are not narcissistic for a while. That’s a very stable kind of personality trait. Borderline issues are notoriously not stable. Uh, when someone is first diagnosed with it, uh, a few years later, very often they don’t meet that, that those same criteria. So that there’s, there’s a progression, you know, really with or without treatment those symptoms tend to modulate. And I think in part when you look at borderline, the heart of being, uh, in, in that kind of a struggle is really about not knowing how to regulate your emotions effectively. And I think that there’s some kind of maturation factor where people, you know, over a period of time get better at modulating their emotions.

Gabe Howard: One of the hallmarks of a borderline personality diagnosis and the way that society often sees people diagnosed with borderline personality is drama follows them everywhere. They create a lot of drama. Is this desire not to seek treatment part of that creating drama, or is it much more difficult to understand than that?

Dr. Connell Cowan: You’re right. Drama does seem to follow them everywhere. Everything is a crisis. And I understand how people can kind of come to that conclusion that this is just another way of doing that. But I think that the way to look at someone who has these kinds of struggles is that this is the way they’re attempting to make sense of their experience. The drama that they that they. Create and they’re creating. It is not an accident. They this is not an intentionally created it’s a way to try and understand and regulate feelings that they don’t know how to regulate in other ways. Uh, and the they will if they see any sign of disapproval, they’re incredibly sensitive. They will they will reject before they’ll be rejected. You can imagine, you know, the concept of fight or flight, which is the kind of classic stress response. You know, the human body is built for that. I mean, that’s helped us survive, but it’s built to get fired and then to calm down. Uh, and for people with borderline personality disorder, they don’t know how to calm themselves. They don’t know how to regulate their feelings. Every everything seems more important than it is. Everything is more sensitive than it really is. So, they live in a state of heightened threat. And that’s really at the heart of the theatrics and drama that you see around borderline people.

Dr. Connell Cowan: You were talking about how do you not kind of drop out when you hear their theatrics? And one of the things that when I when I think about that, when you when you anticipate theatrics, the minute someone gets a few words out of their mouth, you’ve already turned off. Uh, you feel like you’ve heard it all before. And very often that’s kind of the, the human nature response is to just kind of drop the curtain. And I think particularly for borderline people, it’s important to listen to them. And this goes well beyond borderline, but people think they’ve heard everyone’s story so that when someone starts, you feel like you know where they’re going again. And particularly if it’s theatrical or dramatic, you know, it’s like, oh my God, here we go again. They get an eye roll and an eye roll communicates all the judgment that they anticipate.

Dr. Connell Cowan: And so, they don’t feel heard. They don’t feel seen. And if there’s anything that is helpful for human beings in general, and I think borderline people who are incredibly sensitive is the need to be seen and understood. And again, I think that the theatrics, the drama is part of the story that they’re telling themselves. You know, we all as human beings have our story. That’s part of their story. It’s not to be taken personally. It’s hard not to take some of that personally if you’re getting stuff thrown at you. But the way you stay with it, not turn off, is not take it personally to understand it’s about them. It’s not about you. Uh, and, and to understand that it really is generated by an attempt to regulate their emotions, which they’re having a hard time doing. And, and part of those theatrics is, is it’s dysfunctional. It’s not a I’m not I’m not putting this out as a healthy, constructive strategy to regulate emotions. But if you can be the rock, you can be the voice of reason, the voice of compassion and understanding and acceptance in there. Not take it personally. Uh, you stay with these people and they have great value.

Sponsor Break

Gabe Howard: And we’re back discussing why people with borderline personality disorder may refuse treatment with Dr. Connell Cowan. One of the things that I think about when I think about the stigma of borderline personality disorder are all the old men in my life, all of my family members who reach a certain age and their wives are like, hey, you need to go to the doctor. And they’re like, Nope, I’m just fine. And what happens is, is, well, why don’t you want to go to the doctor? What’s changing? We understand you used to be, you know, master of your own domain and you could climb a tree with one hand tied behind your back. But, you know, now you’ve hit 60. Now you’ve hit 65. Now you’ve hit 70. We understand that you are afraid or reluctant or uninterested in treatment, but we’re going to help you understand that you need to go. Now. We take this exact same thing for someone who’s been diagnosed with borderline personality disorder. They say that they don’t want to seek treatment. We immediately throw up our hands and say, See, you’re causing problems again. We don’t address why. We don’t try to comfort. We don’t try to understand. We just immediately say, hey, you deserve whatever bad thing happens to you.

Gabe Howard: And can you believe that? They don’t want to seek treatment. What can we do to shift that? Because every single person I talk to who loves somebody with borderline personality disorder put the blame for not wanting to get treatment squarely on the shoulders of the person with the illness. And that sounds so very, very wrong to me.

Dr. Connell Cowan: Well, it is wrong and it’s more than wrong. Maybe even more important than wrong is that it’s not effective. You know it if it were just prescriptive, you could say, hey, you know, you’re struggling. I see it. I know you must feel it. There are these resources out there. We think that it would really be helpful to you to take advantage of them. Oh, thanks. You know, and it’s not that easy. It the resistance is always about fear. Uh, negativity. That kind of negativity is about fear. And if you don’t address the center of it, you just get pushed back. Um, it’s really interesting. I mean, in terms of, of, of encouraging someone to get treatment, uh, if you push too hard, you’re always going to get push back. If you ignore it, that’s, that’s not a solution either. So, what happens is people tend to push too hard very often initially, and then they throw up their hands and, and don’t do anything. Uh, but I think it really is in understanding the how scary it is for someone who has these kinds of symptoms to put themselves in that position. And if you can if you can offer a little empathy and understanding and compassion for that and encouragement as opposed to judgment. Uh, borderline people are they get judgment thrown their way in buckets and they’ve heard all the judgment. And so that kind of an approach making them wrong is just counterproductive. It doesn’t work.

Gabe Howard: I really like that you said that it’s just ineffective. Whether it’s right or wrong is irrelevant. It’s not going to work and it’s not going to help you achieve your goal of helping your loved one seek treatment. I know that you covered a little bit of this in your previous answer, but I just want to really drill it down. If you love someone with borderline personality disorder who is refusing treatment, is there an action plan or steps that you can take to encourage them to seek treatment?

Dr. Connell Cowan: Well, you know, one of the things that that that I encourage people to do, Gabe, is to offer to go with them. It could be a friend. It could be an intimate partner. It could be a parent. Uh, it doesn’t matter what the relationship is, but very often an offer to go with them for a time or two, um, is a big step ahead. They feel just trusting enough, just confident enough to be able to deal with that. You know, part of it is borderline people feel like they have a long history of being judged. Uh, and, and look for a lot of good reasons. I mean, they they’re difficult people to deal with. So, so that they’ve gotten a lot of judgment thrown their way. And they think therapy is just going to be another judgment, one more person who will find fault with them as opposed to someone who might actually be of help and help them deal with understanding themselves in a little bit different way. So, it’s really how do you overcome that? And it’s kind of quiet encouragement without judgment. And again, I’ve seen it really be helpful to have someone say, listen, I’ll go with you a few times. We’ll do this together. Is just enough to get them over the hump.

Gabe Howard: Dr. Cowan, I know that you have a wealth of information to share when it comes to why people with borderline personality disorder are reluctant to seek treatment or, of course, not seeking treatment. Is there anything that I missed? You have any final messages for our listeners who are trying to encourage someone to get therapy or, of course, someone living with borderline personality disorder who’s thinking, you know what, this is not for me.

Dr. Connell Cowan: Well, I think the most important thing, Gabe, is, and I think this is the most difficult thing. Anybody who has a long-standing relationship with someone who struggles with this has built up a lot of assumptions, and those assumptions carry judgments. And if they could set those aside. It would really be helpful. And I know that that’s sounds probably impossible to do, but I think that to hear them anew is really important. And I think to bring up the value of treatment and to understand that their reluctance to getting into it is fear-based. They don’t want one more person to judge them, one more disappointment in their life. I think if you if you can talk about those kinds of things, so you bring those up. Uh, you dispel some of the fear. And again, I think saying, hey, I’ll go with you. Put yourself in as an ally. You’re not just someone telling them what to do. When you tell someone what to do, they’re in a one down position. You’re the authority. You’re the advice giver. You’re the one who’s offering the instruction. They’re the ones that are they feel like they’re the bad ones being told what to do. When you change that dynamic, you become an ally. You become a partner. That’s why I think offering to go with them for a time or two is can be enormously helpful.

Gabe Howard: Dr. Cohen, thank you so much for being here. I understand that you just wrote a new book.

Dr. Connell Cowan: It’s called “Override.” And it’s basically the ways that our brain chemistry kind of pushes us around in ways that we’re not aware of. And it explores how those dynamics work for us and in everyday life. And so, we’ve learned how to build some very specific easy to use strategies that take into consideration the kind of brain type that you have.

Gabe Howard: Thank you once again so much for being here. We really appreciate it.

Dr. Connell Cowan: Well, Gabe, it was a real pleasure. It was a pleasure talking to you, and again, I just want to say that you’re a bright light and a necessary one to be shining out there, you know, for people and, you know, keep it lit.

Gabe Howard: Oh, thank you so much. I really appreciate that. And I will keep it lit as long as there are listeners allow me to.My name is Gabe Howard and I am the author of “Mental Illness Is an Asshole and Other Observations.” You know what else? I am an award-winning public speaker who may be available for your next event. The book is on Amazon because, well, everything is. But you can grab a signed copy with free show swag or learn more about me just by heading over to gabehoward.com. Wherever you downloaded this podcast, please follow or subscribe to the show. It is absolutely free and hey, can you do me a favor? Recommend the show Sharing the show is how we grow. So, tell everyone you know. I will see everybody next Thursday on Inside Mental Health.

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