Understanding and helping individuals with BPD

For the month of May, BPD awareness and education is front and centre. Instead of sharing more education that is already out there, I choose to share my personal experience working with these individuals. 

Borderline Personality Disorder (BPD) has traditionally been a feared diagnosis. In therapy sessions, client’s have asked me tentatively, “Do I have BPD? Am I screwed? Is this the end?”. Many individuals with BPD share moments of feeling ‘crazy’, ‘disconnected’ and terribly ‘unsure of themselves’. Clients tend to report difficulties with connecting and respecting boundaries and often, feel out of control and alone in their struggles. 

As a clinician it is no walk in the park. Clinicians describe individuals with BPD to be complex, difficult clientele and many a time, struggle with self-doubt whilst engaging in the work. Each session at times feels like a battle with clinician and client getting ready for “war”. “What are we doing this for!” is probably a question that frequently runs through clinicians’ minds. 

If you can identify with being an individual struggling with BPD or a clinician struggling to manage your clients, I want you to know that you are not alone. I see you and your struggles, and these are all valid and meaningful experiences. 

It may be hard to see this at times but individuals with BPD are not inherently bad or mean and out to get the world (even if their behaviour might lead one to think that way). I like to think that individuals who have a diagnosis of BPD are usually kind at heart but really lost in their ways. Look deeper beyond the “prickly shell” and you will see a little child part of themselves, lost, hurt, and crying out for help. Many of these clients have not ever had a chance to experience what is “good” for them and have unfortunately experienced constant stress or abusive situations resulting in the development of such a personality disorder. BPD is like a fierce protector with no guidance – killing everything and everyone that comes close without the ability to distinguish who is the real enemy.

Tiring? Definitely. End of the world? Most definitely not.

The idea of duality is quite important when working with individuals with BPD. One feels emotions intensely and this can mean intense sadness or despair AND intense joy and excitement. One can experience unstable relationships AND have meaningful experiences through the relationship. There is an understanding that one is doing the best they can AND we know they can do things differently (or better). In my work with these clients, I have found that the practice of validation and sitting with can be a very powerful experience. Learning how to sit with and look beyond the unhelpful expressions of pain to connect the client with their struggling inner child is crucial. Providing space to for this inner child to breathe, to be heard and to feel a sense of safety is what helps strengthen the bond between our clients’ current selves and their vulnerable inner child. This leads to opportunities to heal with an increased willingness to experience the spectrum of emotions that comes with being human. 

I have found working with these clients a challenging, stressful and yet meaningful experience. I feel humbled to have learnt a great deal from those whom I have had the privilege of crossing paths with and this process is something I will always value in my work as a clinician. All our experiences are unique and I hope that you will find your space as you embark on this journey as well.

Written by:

Dr Cherie Chan

Clinical Psychologist

Doctorate in Clinical Psychology

MSPS, Registered Psychologist

Self-care for new moms

Nursing, burping, changing poop-filled diapers, learning how to put your infant to sleep, coping with the after effects of delivery, feeling like your body is no longer your own, sleep deprivation – there are so many things to do and so much of it is so new after giving birth. New motherhood is fraught with the challenges of what is essentially both a transitional period as well as the addition of another role to a woman’s life. It’s no wonder that self-care often falls by the wayside. 

Whenever I see a new mother (defined by having given birth in the last year, inclusive of all first/second/third time mums) in my office, and ask about how they are feeling and taking care of themselves, I usually get a half-smile and a scoffing sound. They indicate that they know that self-care is what they “should” be practicing but for one reason or another, can’t. According to Barkin and Wisner (2013), unhealthy degrees of selflessness, which is also associated with good parenting, can also get in the way of setting boundaries and caring for your own self. This then can lead to feeling like a failure perpetuating an unhealthy cycle of negative thinking.

Hence, self-care of new mums needs to start with a very basic NESTS plan:

  1. Nutrition: are you eating 3 meals and a few snacks a day? Keeping a healthy snack bag handy for home as well as for when you head out is crucial to maintain energy levels. Give yourself permission to accept food from family and friends, and to plan and prep for meals ahead of time.
  2. Exercise: start with 5 minutes a day after clearance from your doctor and if you feel like doing more, go for it! Start with something you have enjoyed in the past eg dancing, walking, yoga and you will notice a small but remarkable change in your energy and emotions.

You can take baby along for a walk in the carrier or stroller or even for a fun mum and baby yoga class. 

  1. Sleep and rest: new mums are highly attuned to their babies and newborns can be very noisy sleepers! So if you find yourself being highly alert to the slightest movement or sound from baby when they’re asleep, try and hand over your sleeping baby to another caregiver to look after and get some rest yourself. 
  2. Time for yourself: this is the hardest part as it is the most guilt inducing. Try taking short breaks through the day instead of hoping for a long one, or cutting further back on sleep to get some me-time. Even if it is 10 minutes to sit by yourself and drink a cup of tea or taking 15 mins to chat with a friend, it will help you feel like yourself again. 

Reading books or watching fun shows on TV when breastfeeding is also a good way to unwind.

  1. Support: the benefits of a good support system is incalculable –  it may be someone you trust who looks after the baby while you eat, sleep or shower; they maybe friends who drop off healthy food on a regular basis. Line up some friends who will check in on you regularly. 

Motherhood can be lonely and a group of new mums whom you can check in with, people who will be awake at 2 am when you are – is invaluable and Singapore offers many new mother support groups. Having a team of medical support – a great gynaecologist for you, a paediatrician you trust, a lactation consultant and/or a postpartum doula, a confinement nanny, a therapist – you can rely on for solid advice can feel hugely supportive to new mums. There are several services in Singapore that offer free or low cost support. 

Make a list of your support system while still pregnant and let them know specific ways they can be of help after the baby arrives. 

If implementing these habits feel exceptionally challenging, consider if any of the following are getting in your way:

  1.  Limited time and resources: several women reported not having time for themselves upto two years after birth. Some described the struggle of managing on a small budget (Barkin and Wesner, 2013)
  2. Difficulty setting boundaries: some women say that there are there too many visitors coming around to hold the baby or an overbearing confinement nanny who completely takes over and does not let them do anything for the baby. Consider saying no and asking for what you need – whether it is someone holding the baby while you eat, sleep, shower or unwind or whether it is supporting you to hold the baby while they clean, cook or help otherwise. It may sometimes mean educating people around you that support means caring for the mother as much as caring for the baby. 
  3. Difficulty accepting help: many women described their own behavior as a barrier to effective self-care. Despite having people willing to lend a hand, they were unable to fully trust their partner/husband to take care of their child even though they had been fully capable in the past. Guilt can also be a factor in difficulty placing a high priority on their own needs and setting boundaries (Barkin and Wesner, 2013). Managing the guilt complex with the help of a therapist can be a good starting point. 

As a new mum it is vital to be compassionate towards yourself and your struggles. Take it slow – one day at a time and lower your expectations of what you can accomplish in a day. Most significantly, remember to enjoy your baby and know that there will come a day when things will get easier and you will feel like yourself again. 

Written by:

Radhika Haralalka

Counselling Psychologist

MSc (Counselling Psychology)

MSPS, Registered Psychologist

Self-Compassion Practice

Picture sitting opposite a client, who is getting more agitated by the minute, and exclaiming that therapy is “not working”. Or pushing a cart down the supermarket aisle as your toddler has a screaming meltdown because chocolate is not on your shopping list. Or being distracted by emails whilst the dinner burns to a crisp in the oven. In your head comes a familiar foe, your critical voice, “You’re an idiot! Look what you’ve done now! You’ve ruined it all!”

We are sometimes our own worst enemy – berating ourselves in a way that we would never dream of communicating with anyone else. This inevitably leads to us feeling worse. Instead of judging and criticising ourselves when confronted with our own mistakes, failures, or shortcomings, self-compassion means to be kind and understanding to ourselves. We are after all only human, who ever said we were supposed to be perfect?

Research indicates that self-compassionate people experience:

  • Greater motivation and self-responsibility
  • Improved mental-wellbeing
  • Increased happiness and life satisfaction
  • Healthier lifestyle behaviours
  • Better interpersonal relationships
  • More effective coping with difficult life experiences

A simple way to practice self-compassion is by giving yourself supportive touch. Physical touch activates the parasympathetic nervous system, releases oxytocin, soothes distressing emotions, and helps us calm down and feel safe. When you notice you’re stressed, take three deep breaths, and give yourself supportive touch. Some ways to do this are by placing your hand over your heart or on your cheek, cradling your face in your hands, softly stroking your arms, crossing your arms and giving a gentle squeeze, or cupping one hand in the other in your lap (this subtle one can be helpful in difficult sessions with clients!). Notice the gentle pressure and warmth on your skin. Linger with this feeling of physically comforting yourself, when needed.

For more information on self-compassion practice and research findings, please visit: https://self-compassion.org/

Written by:

Dr Siew Soon Peng

Clinical Psychologist

PhD in Clinical Psychology

MSPS, Registered Psychologist

Are we really offering a helping hand?

“Can you please help me to hold the door?”

“Would you please tell me if that was okay?”

One of the many challenges in addressing obsessive compulsive disorder (OCD) is the presence of family accommodation. The term family accommodation (FA) describes changes that individuals (e.g. parents, partners, siblings, and children) make to their own behaviour, usually well intended to assist their affected relative avoid or alleviate distress related to the disorder.

FA may take several forms, ranging from engaging in excessive hand washing to helping to reduce contamination fears experienced by a loved one, listening to repeated confessions of a relative who feels the need to constantly confess, providing excessive reassurance, as well as removing knives to reduce or alleviate the distress of a relative with aggressive or suicidal obsessions. The below table listed some examples of FA in OCD.

Table 1. Examples of family accommodation in obsessive-compulsive disorder organised by obsessive-compulsive disorder symptom dimension and type of accommodation

Forbidden thoughts and checkingSymmetry and orderingContamination and cleaning
Avoidance of OCD triggersCutting food for patient because of the fear of knivesRefrain from moving furniture or making changes in the homeOpen doors for patient
Improvement in compulsionsListening to patient’s confessionsTouching both sides of the patient (e.g. kissing both cheeks)Buy special/extra soap

FA is common. In fact, researchers reported that 96.9% of the relatives of patients with OCD engaged in accommodative behaviour, with the degree of accommodation ranging from mild to extreme.

What can be so bad about these FA behaviours? Well, research informed that FA predicts symptom severity and functional impairment with more accommodation being associated with worse clinical presentation and poorer treatment outcomes.

With a close examination of the behaviours, we can notice that FA functions in the same manner as a ritual, in that obsessive-compulsive distress is reduced, thereby negatively reinforcing further symptom engagement. The accommodation of symptoms conflicts with the primary goals of cognitive-behavioural therapy (which is an effective and recommended treatment for many with OCD) for OCD and can be an obstacle to positive outcomes.

Furthermore, FA has various negative impact on the ‘helping’ individuals. Research highlighted that increased FA was found to be linked to poorer caregiver health, lower quality of life and increased caregiver burden.

Are we really offering a helping hand?

As highlighted earlier, FA is common and you are not alone in this struggle. If you notice that you are carrying out some family accommodation behaviours, have a discussion with your therapist to explore how you can be more effective in providing a helping hand in your love one’s recovery, as well as caring for your well-being in the process.

Written by:

Adrian Toh

Clinical Psychologist

M.Psychology (Clinical) (Singapore)

MSPS, Registered Psychologist

Bringing your child to therapy

Coming to therapy can be stressful when you don’t know what to expect, especially for children and teens who are usually not the ones initiating the demand for support. Parents can dread the conversation and have often asked me how to inform and prepare their children for their first session.

You will approach the conversation differently depending on the age of your child, their circumstances, and the specificities of the therapist you have chosen (art therapist, counsellor…). However, here are some guidelines that can help you out despite these factors:

Find a therapist that you and your child can feel comfortable with. Base your reflection on the knowledge you have of your child, previous experiences with teachers/educators or cultural preferences. Your referring doctor and the administrative team of the practice are able to support you in this decision. Most professionals and practices have now also their own website detailing their expertise and providing pictures of their therapists and office space. Once the session is booked, seeing these pictures will reassure your child or teen and give them a better idea of what to expect.

Pick your timing. Avoid bringing the subject into an argument or during a highly stressful situation. Refrain also from using therapy as a threat, punishment, or leverage to get your child to “behave”. Prefer a calm moment to start the conversation and make sure you have time to answer your child’s questions or help them process what it means. If they are not making a bid deal out of it, it might be better to move on. If you are the one insisting and making sure they are okay with the appointment, they may think that they are not picking up on something they should worry about.

Stay away from the blame game and pressuring comments. We don’t want to guilt or shame the child into going to therapy. Nor do we want them to feel stigmatized and responsible for the wellbeing of the entire family. Pointing fingers could lead to defensiveness and refusal. Other types of pressures may interfere with their engagement in therapy such as giving instructions on what to say and not to say or highlighting the cost of sessions as a lever for payback in a good attitude.

When talking about the difficulties that need to be addressed in session, discussing specific and observable behaviours is more conducive to fostering commitment and cooperation. You could say things like “I am noticing that it’s hard for you to stay calm when /that you don’t seem happy about /that there has been a lot of fighting in the family”.

Therapy is a team effort between the therapist, the child and the family. In any collaborative work, each person involved has their function, their pace, and their process. Parents can model patience and compassion for their children.

Try being honest about the nature of the appointment. Misleading description (e.g., “we will just have a regular chat with a nice lady”), false promising (e.g., “it’s going to be so much fun; you’ll see!”) or disguising the truth on where they are going (e.g., “we are just going for lunch/to visit one of mom’s friend”) may do more harm than good. It will bring your child to the consultation room, but they may feel betrayed, disappointed, and close off as soon as they arrive.

Prefer an encouraging tone by focusing on how therapy is a resource. You can say things such as “we are going to meet with *name of therapist*. Their job is to help people feel better / to help kids make friends more easily / to help deal with all of these strong feelings that show up sometimes / to help kids feel safer and more relaxed at bedtime”. You can also use your child or teen’s words on how they describe their struggles “you have told me that *issue*, *therapist’s name* can help you figure out what to do about that”.

You can add that the therapist may ask questions to know more about them, but remind them that it is not a test, that there is no right or wrong answer and that they are not forced to discuss anything they don’t want to. Depending on the age of your child and the information you gathered from the therapist, you may also mention that they may be offered to draw pictures or play games.

It’s better to not overwhelm them with details and run the risk of misinformation. You can admit that there are certain things you don’t know and encourage their curiosity to find out themselves and tell you more once the first session is over.

If the child is reticent, you may try creating a positive and pleasant ritual around the appointment like spending some time together before or after the session. However, refrain from using it as a bribe e.g., “if you go to therapy, I will take you for ice cream after!”.

Therapists work hard to make the therapeutic work appealing and playful to engage children and teens, but the core of the work is still about addressing struggles and hardships. It may not always be fun or easy but that is okay, as with school, medical appointments, or with life in general, some things are important and necessary to carry out.

If despite all your efforts, your child or teen absolutely refuses to attend, ask the therapist for further guidance. They may offer you to attend some parental sessions to analyse the identified difficulties and learn new strategies to address them and connect with your child.

Written by:

Lucie Ramet

Clinical Psychologist

MSc in Clinical Psychology and Psychopathology (Hons.)

The role of religion in mental health

Living in Singapore, we are exposed to a variety of religions and rituals. Born into a Buddhist family, we carried out rituals (e.g. cooked food for the ghosts during Hungry Ghost Festival). In addition, as a student in a Catholic school, I remembered hunting for Easter eggs and attending mass during Good Friday. And now as a Christian, religion encompasses my life including my mental health. I remembered during my recent baby blues, besides seeking help from people, reading Christian books helped me cope emotionally.

Further, as a psychologist, I work with clients from various backgrounds including Christians. Having a similar religion provides another avenue to connect with the client. Hence, it builds the therapeutic relationship which then contributes to better therapeutic outcome. However, I am mindful that Christians may have different beliefs as churches may differ in their biblical teachings. Thus, being in a secular setting, I would usually check if they are comfortable using religion in the therapy session.

Moreover, I also work with LGTBQIA2S+ clients. Having a close relative in this community has taught me how to relate to clients in this community despite my Christian beliefs. However, it is inevitable for our beliefs to affect our thoughts. Hence, being cognizant and reflective of what goes on in the therapy session allows one to create a positive therapeutic relationship.

Lastly, religion is shown to be a protective factor for our mental health. For instance, it provides a purpose in life. However, I have noticed how religion can make one feel guilty and if not dealt correctly it can affect one’s mental health. Therefore, I believe religion and rituals may be easily overlooked but it actually has a powerful impact on our lives.

Written by:

Beverly Tan

Counselling Psychologist

Masters in Applied Psychology (Counselling) (Singapore)

MSPS, Registered Psychologist

Mindfulness for Children/Youth

Mindfulness has garnered much interest and you may be wondering what is it all about? Often, there is a misconception that mindfulness is about achieving calmness and emptying our mind. However, mindfulness simply defined, is paying attention to what is occurring in the present moment, non-judgmentally. It could be related to our experiences – such as what we think and feel and what we experience through our five senses.

I’d invite us to think about how many times we’ve operated on ‘autopilot mode’ (not paying attention to what we are doing in the moment/just going through the motion). For instance, washing the dishes and thinking about what needs to be done next, watching television or using our phones mindlessly, having a meal with loved ones and scrolling through social media.

A growing amount of research has shown the benefits of mindfulness for youth’s wellbeing and mental health, such as, helping them recognize worry, increased coping and resilience, problem-solving skills in social and emotional aspects, self-esteem, and self-regulation of behavior (Carsley et al., 2017; Zenner et al., 2014).

The practice of mindfulness may include formal practice such as mindfulness meditations and informal ones. For instance, noticing the colour of leaves when out for a walk at the park, blowing bubbles and noticing the shapes, intentionally slowing down and focusing on a part of their morning/evening routine – noticing how the soap or the water feels when their taking a bath. With children, it may require some creativity, like my favorite one from Dr. Russ Harris – to mindfully eat a gummy sweet and to notice the smell, colour, taste, and texture (it’s also a kid favorite too, because who doesn’t like candy!).

Written by:

Vidhya Renjan

Clinical Psychologist

M.Psychology (Clinical)

MSPS, Registered Psychologist

Amplifying autistic voices

In honour Autism Acceptance Month in April, I want to highlight female autistic individuals on LinkedIn who can advocate for themselves and their community much better than I can. It is important in our work to amplify autistic voices, share resources written by autistic people and support autistic people in their school, work and businesses.

This month I am focusing this post on female voices as there is still a long way for professionals to go in understanding and supporting women on the spectrum. I hope to raise awareness by sharing a small selection of inspiring women with autism, from across the globe, I encourage you to follow on LinkedIn:

Robyn Steward

Rochelle Van Heerden

Mollie Pittaway

Nicky Collins

Christina Keeble

Bianca Toeps

Charlotte Valeur

Melanie Sykes

To help people appreciate the diverse lived experiences of those on the autism spectrum, here is a video by AutismBC that showcases some individuals talking about what makes them unique.

Written by:

Dr Jennifer Greene

Educational Psychologist

DEChPsy (UK)

MSPS, Registered Psychologist

What’s the deal with schema modes?

Image result for schema

Firstly, schema is a mental structure that an individual uses to organize knowledge and this in turn, guides cognitive processes and behavior (e.g. schema for a dog). A schema is formed since young and problems may occur when we develop early maladaptive schemas such as the following:

1. Abandonment
2. Mistrust & abuse
3. Emotional deprivation
4. Defectiveness
5. Social isolation
6. Dependence
7. Vulnerability
8. Enmeshment
9. Failure
10. Entitlement
11. Insufficient self-control
12. Approval seeking
13. Subjugation
14. Self-sacrifice
15. Unrelenting standards
16. Negativity/pessimism
17. Emotional inhibition
18. Punitiveness

The schema mode model is used to help an individual with complex presentation of more than 6 maladaptive schemas.
This model comprises of the following:

Child modes:
Angry and impulsive

Critic/Parent modes:
Guilt inducing

Coping modes:
Compliant surrenderer
Detached protector/self-soother
Overcompensator (worksholism)
Aggrandizer (narcissism)
Bully & attack/predator (forensic)
Perfectionistic overcontroller (OCD, eating disorders)

Healthy adult (client subsequently assumes this role from the therapist)
Compassionate, assertive, limit setting

The aim of this therapy is to:

Develop AWARENESS of schema modes

BYPASS maladaptive coping modes

DISTANCE from critic modes

STRENGTHEN the healthy adult

Such therapy may be used with individuals as young as adolescents and if you are working with children, you may also consider dealing with your own schemas and modes! This helps you improve on your reactions when working with individuals and hopefully they will respond better too.