Born Borderline?

Yesterday there was a discussion in a Facebook group about whether borderline personality disorder could be a brain condition you're born with. The original poster started by saying she feels so broken and has her whole life that she wonders whether BPD is not just a mental disorder, but a brain dysfunction.

Now I want to say that a more severe disturbance has nothing to do with whether you were born with the condition. It's not like, if you were born with it, that it's necessarily any worse thn if you acquired BPD as a result of childhood trauma. Some commenters mentioned feeling their wacky childhood may've been due to their BPD rather than vice versa. Does it truly matter? I don't think so. Like, people are usually born autistic, but this doesn't mean all that happens to the autistic growing up is due to autism.

From what I understand, BPD is caused by a combination of temperament, which is largely genetic, and childhood circumstances. There was this debate in a Dutch women's mag a few months ago about two parents of BPD adults saying they didn't like the assumption that BPD is trauma-based because they didn't abuse their children. Then someone with BPD responded that even the most ordinary parents make mistakes, and this can set off BPD in vulnerable people.

Let's move away from black-or-white thinking in the nature/nurture debate. Let's also move away from blaming ourselves when something is brain-based, or feeling more broken for it, and from blaming our parets when something cannot yet be shown to be brain-based. Therapy can change brain function. So can other environmental circumstances, like trauma. When we have a brain dysfunction, we may perceive experiences differently. The two basically interact.

I remember when the Dutch organization that oversees health insurance proposed to drop mental health coverage for people who'd gotten mentally ill as a result of life circumstances. Have we truly gone backwards that much, believing that the brain and mind are two entirely separate entities? Science shows that, with mild depression for example, it doesn't matter whether it's due to recent divorce or it comes out of the blue, a wait-and-see approach is always best. With severe depression, not so. And as for BPD, it's usually severe enough to warrant treatment whether it's brain-based or not.

Moving Beyond Blame in Abuse

A few days ago, Soaring Survivor wrote an interesting post on forgiving yourself in the process of healing from domestic violence. Forgiving yourself, she says, is harder than forgiving the abuser.

I always find myself thinking that my situation is almost unique, in that I myself was aggressive and my family responded with aggression to my behavior. Then I found out, I don't remember where, that in most situations of intimate partner violence, there is not simply one person who is the perpetrator and the other who is the victim. Rather, there tend to be some form of abuse on both sides. I am not saying that this is the case for Soaring Survivor, as I don't know her situation. What I mean to say is that my situation, involving sort of provoked aggression, is not as unique as I used to think.

This makes forgiving myself extra hard. I have forgiven my family, I think, but too often this comes down to trivializing what happened. I know that my parents weren't sadists, and I often say this to justify their actions. They did what they thought was their best.

Then a few weeks ago I read a response in a women's magazine from a person with borderline personality disorder to two parents who had complained about their children's BPD being attributed to abuse. The borderline patient said that even very ordinary parents make mistakes, and this can set off BPD in vulnerable people. Does this mean they're pitiful victims? No.

What I realize as I write this, is that maybe the hardest part of forgiving both yourself and the people who hurt you in your life, is shifting the focus away from the question of blame. Ordinary partners and parents (and children) act out violently, and accepting this is hard but necessary for both survivors/victims and the general public. Abuse happens, and the idea that only sadists perpetrate it, gets a whole lot of survivors/victims unnecessarily stuck in self-blame. Forgiveness may involve accepting what happened without letting it hold you back from living a fulfilling life. I'm still struggling with this.

Pathological Demand Avoidance (PDA)

A few months ago, I became a member of some groups for pathological demand avoidance. Pathological demand avoidance (PDA) is a term coined by Elizabeth Newson from the UK for a set of symptoms that she claims are part of a distinct autism spectrum disorder. These symptoms include:

• Obsessive resistance of everyday demands.
• Appearig sociable on the surface but lacking deeper social understanding.
• Excessive and sudden mood swings.
• Language delay, possibly due to passiveness./LI>
• Obsessisve behavior, often focused on people rather than things.
• Comfort (sometiems excessive) in role-play and pretending.

People with PDA are thought to have high anxiety and a need to be in control. This causes them to actively and/or passively resist demands placed on them by others.

I am not yet sure what I think of the existence of PDA. Is it yet another pathologization of annoying-but-normal behavior, or, worse yet, is it the new drapetomania? You know, the compulsive running-away of slaves? What I mean is, is it, a healthy response to excessive authority? I was discussing something like this with my therapist last Thursday. I didn't mention PDA - we're treating my symptoms as part of borderline personality disorder -, but now that I think of it, I realize that the idea of PDA fits in neatly here. I have a seemingly compulsive need to resist expectations from others. Until I spoke about this to my therapist, I've always said this is a normal part of rebellion against the institutional system I'm in. Or is it? I resist attempts to give me responsibility for my own life, too, and eaarlier last week, realized I wasn't sure I wanted to recover, out of fear of losing my support before I was ready.

Now I am not advocating labeling people with more diagnoses than they need. In my own case, it could well be that my problems are due to a combination of autistic overload, BPD-related identity confusion and having lived in situations where others determined my goals for much of my life. I am still unsure as to whether my therapist is not one of these authority figures, who wants independence only insofar as it isn't defying her idea of who I am.

An important thign which Newson highlights in relation to PDA, is that ABA-style behavior modification does not work with PDA children (or presumabley adults). The therapeutic relationships is much more important than it is presumed to be in behavioral interventions. I like this, although I feel the therapeutic alliance is important for others with autism spectrum disorders too.

One thing I don't like about Newson's theory, is that she presumes PDA sufferers to be manipulative. Now I am not one to say that autistics can't manipulate - they can and do -, but here comes the question again of where manipulativeness comes from: is it an innate PDA chharacteristic, or is it learned behavior in an attemt to manage a hard-to-cope-with environment? Newson assumes manipulation in PDA is not something the child chooses out of a will to be annoying, but out of a need for control and to avoid anxiety. Overload, of course, is often confused with anxiety, so in this sense I'm not too sure that I think.

Need Care? Be a Pain in the Neck

Over the past couple of weeks, I've been pretty fearful of losing my autism diagnosis now that the DID/PTSD was changed to BPD. I've had a number of arguments with various people over whether certain aspects of me, like my inability to live on y own or with little support, are due to autism or due to BPD. The answer matters in some way, because, as I said a couple of weeks ago, if it's BPD, it means it can be treated with cognitive therapy.

Now I have always been very adamant that my inability to live on my own is due to autistic organizing and processing difficulties. To the person believing the inability is due to BPD, this comes across as defensiveness: I'm just scared to take repsonsibility for my own life and I use autism as an excuse.

Unfortunately with this comes the idea that this fear will go away if I just get enough kicks in the butt. I know that flooding is used in anxiety treatment, but is it truly the most appropriate way of treating the fear of taking responsiiblity for your own life, assuming this is indeed what is going on?

I've often wondered and worried how people are going to tell that they are wrong in assuming that all my inabilities (except for those that are obviously due to blindness) are just insecurities. I mean, the only time I succesfully signaled that I needed more support, in 2007, I did so in a very much borderline way, ie. by threatening suicide in a public place. It is easy to say that this is my BPD acting up and I need to be ignored.

Of course, the currently mentally healthy person would say, why don't you just ask for more help in an appropriate way? Now I will tell you something about the way the care system works here: depression, anxiety or other emotinal problems are no grounds for care. Only behavioral problems are. In other words, if you need help, you've got to be a pain in the ass. Now please untangle this reality for me: if you're still well-behaved enough to signal you need help without destructive actions, you're obviously healthy enough not to need this help. Now if that isn't reinforcing behavior problems, I don't know what is.

Research Recommendations for Improving Treatment for People with Personality Disorders

Two studies in nursing journals that I read recently examine good practice for personality disorder treatment. Bowen (2013) specifically studied ideas for intervention with borderline personality disorder patients, whereas Fanaian, Lewis & Grenyer (2013) studied more general ideas for implementing personality disorder services. Bowen also emphasized direct intervention strategies, whereas Fanaian et al.'s study more focused on organizational structure. Bowen (2013) interviewed nine mental health professionals, four of whom were nurses, working at a specialist unit for patients with BPD. Key apsects of good practice mentioned by interviewees were:

• Shared decison making: for example, service users and staff should meet in community meetings to discuss and think through decisions that a service user might otherwise make impulsively. This thinking thorugh also counters black-and-white thinking.
• Rules should be actively recreated, rather than being strictly enforced or being abandoned. This is an offshoot from the shared decision making in the above bullet.
• Patients should have social roles, such as jobs on the unit nd group therapy with a pratical focus. This is a way of bringing into the open and then challenging interpersonal difficulties that are so typical of BPD.
• Social disturubances must not just be prevented, but also be used as an opportunity for learning.
• Peer support, including feedback on behaviors, but also including compassion. One interviewee also commented that peer support can enhance the patients' looking inward for the resources to help themselves, rather than viewing the staff as sole bearers of wisdom.
• Open communication. For example, this unit had a structure whereby three service users were elected to discuss issues happening on the unit with the staff as a means of liaison.
• Involvement with the person as a whole, seeing them as more than their BPD symptoms.

Bowen (2013) does highlight that not all of these aspects of good practice can be generalized. After all, this unit was a specialist unit for treating BPD and had its structure built so that these aspects of good practice could be met. For example, there were daily meetings, group therapy, and patients had jobs on the ward.

It was found that mental health workers on this unit had a pretty optimistic outlook on recovery from BPD. This is in contrast to research which shows that mental nurses have negative attitudes about BPD patients. Fanaian et al. (2013) emphasize this negative attitude towards people with personaltiy disorders as a major barrier to appropriate care.

Fanaian et al. (2013) had about 60 experienced clinicians in personality disorder treatment, including psychiatrists, psychologists, social workers, a nurse and a counselor sit in groups of four and brainstorm on topics relevant to personality disorder treamment. They overwhelmingly found that current practice in mainstream mental health settings is both poor and inaccurate. Ways to improve practice included:

• More education and training on the subject. Some groups also recommended that workers in non-psychiatric settings who have frequent contact with personality disorered people, such as social services staff, be trained in personality disorders. Carers, such as family and friends, also were said to need education and training.
• More support through supervision and leadership. For example, there should be more supportive and regular treatment team meetings. Clinicians also mentioned better access to Internet resources on treatmetn and assessment for mainstream mental health staff. There also should be greater support for staff approaching burn-out, as it was felt that staff working with personality disordered people have a high risk of burn-out and work-related stress.
• A shift from risk management to recovery-focused treatment and case management. Acute hospitalization should be avoided when possible. Rather, patients with personality disordeers need intensive, multidiscipinary case management.
• Clearer guidelines and protocols. Many groups of clinicians emphasized a consistent approach across teams, particularly when managing crises.
• An attitude shift to decrease stigma. Some groups emphasized the fact that many health professionals have a negative attitude about personalityy disorder patietns, and this is a barrier to effective treatment.

Fanaian et al.'s (2013) study, like all studies, has its limitations. The clinicians participating in the study were invited to a personality disorders meeting based on expertise and experience. Therefore, it is not known whether these findings generalize well into mainstream mental health provision.

References

Bowen M (2013), Borderline Personality Disorder: Clinicians' Accounts of Good Practice. Journal of Psychiatric and Mental Health nursing, 20(6):491-498. DOI: 10.1111/j.1365-2850.2012.01943.x

Fanaian M, Lewis KL, & Grenyer BFS (2013), Improving Services for People with Personality Disorders: Views of Experienced Clinicians. International Journal of Mental Health Nursing, 22(5):465-471. DOI: 10.1111/inm.12009.

BPD Subtypes

When searching for information on BPD, I came across a set of subtypes that describe the various features of BPD. These subtypes are:

• Discouraged: this type of borderline is either avoidant, believing no-one will like them anyway, or overly dependent on others. They have an intense fear of abandonment. Borderlines of this type may also suffer from depressive symptoms.
• Impulsive: this is the most hated BPD type among professionals. People who are primarily impulsive tend to act before thinkign. This includes violence or other antisocial behavior. Conversely, they may also engage in constant approval-seeking.
• Petulent: borderlines of this type use passive-aggressive behavior, including emotional or physical self-abuse, to get their needs met by others. They have an intense fear of abandonment,, unstable self-image, and inability to express their needs properly.
• Self-destructive: this includes depressive and self-harming tendencies. People of this type may not have many BPD traits other than self-injury and affective instability, so they may not technically meet the criteria of BPD.

Please note that people with BPD may have some features of one type and some of another. I, for one, have features of the discouraged and petulent types.

All types except for the petulent borderline operate in an abandoned child mode. Petulent borderlines operate in an angry child mode. I do see this point, but I want to stretch that the angry child usually masks the needs of the abandoned child, as my therapist explained. I myself cannot feel sadness unless I've first expressed intense anger or rage. Yesterday, I found myself in such a situation. I had had a minor conflict with my husband which led me to fear abandonment. As I got back to the ward, the nurses were assuming I'd had a good day - after all, it was my anniversary -, and were encouraging me to think positvely. Now I could and maybe will at one point write up a whole post on the positivity paradigm, but suffice it to say I snapped. I had a rage that, after a lot of back-and-forth screaming between me and the nurses, led to me running off and wandeirng around grounds screaming. I could only start to feel the sadness and fear of abandonment after I'd blown off some steam and calmed down again.

Autistic Processing Difference vs. Cognitive Distortion

Today, I experienced a combination of emotional turmoil and sensory overload. Which came first is hard to tell, as I was having oversensitivities already for an hour or so, but the actual reaction, which is either a meltdown or an emotional breakdown, was caused by frustration. Given that both autism and borderline personality disorder come with distress tolerance issues, it is hard knowing which is to blame. It doesn't really matter, except that the two require different approaches. BPD treatment involves skills training in distress tolerance, learning to shift your idea that you can't handle frustration to the idea that you prefer not to get furstrated. Autistic distress tolerance issues involve an increased need for routine and time to adapt to a sudden change in that routine.

When sensory overreactivity comes into the equation, it gets more complicated. If this is assumed to be an emotion regulation or distress tolerance issue, people need to learn to accept that sometimes there's noise they don't like. When people still didn't acknowledge my autism, I was often told that it's other people's right to make noise, as if I was depriving them of that right with my reaction to overload. In autism, however, noise can be painful, and the right approach is to allow the autistic quiet time away from the overloading stimuli.

Now that I write this, I notice that I'm connoting that the treatment I assuem is perceived to be right tfor BPD is really not that right at all. In fact, I believe that you cannot assume that a problem with distress tolerance is ever true unwillingness to accept that things can't happen on your terms all the time, which is what is assumed in personality disorders. There are some people who are truly unwilling to take others' feelings into account, but this si much rarer than the assumption that people are unwilling to take others' feelings into account. I realize that cognitive distortions are not necessarily willful, and that the thought that you can't handle any frustration is not the same as the thought that the world revolves around your need for gratification. What I mean to say, however, is that most people, and especially autistic or otherwise neurodiverse people, do not just think they have difficulties. We genuinely do process stimuli differently, and this means that "can't" is not just a cognitive distortion most of the time. That doesn't mean that autistics doon't have cognitive distortions, too. What it means is that you need to take into account autistics' genuinely different processing style when assessing or treating cognitive distortions. As I was being told for the umpteenth time that my daily living skills deficits are largely due to fear of failure, I begun to wonder whether NTs can truly evr make such a judgment.

Meme: 30 Things About My Invisible Illness

I found this interesting meme for invisible illness week, so here goes.

1. The illness I live with is: undiagnosed other than mental illness (borderline personality disorder).
2. I was diagnosed with it in the year: not diagnosed for my physical symptoms. Diagnosed with BPD in 2013.
3. But I had symptoms since: 2007.
4. The biggest adjustment I’ve had to make is: taking meds everyday.
5. Most people assume: my illness is unreal because it's not diagnosed.
6. The hardest part about mornings are: waking up tired.
7. My favorite medical TV show is: House.
8. A gadget I couldn’t live without is: my mobile Internet modem.
9. The hardest part about nights are: going to sleep on time, pain.
10. Each day I take __ pills & vitamins. (No comments, please): 6.
11. Regarding alternative treatments I: have not tried them but am open to some.
12. If I had to choose between an invisible illness or visible I would choose: visible.
13. Regarding working and career: I don't work, have never worked. I was given disability benefits with no problem based on my visible disability which is the least of my disabilities.
14. People would be surprised to know: that I'm in pain even when I don't show it.
15. The hardest thing to accept about my new reality has been: that I can't live with my husband.
16. Something I never thought I could do with my illness that I did was: take a university-level course.
17. The commercials about my illness: I've never seen/heard any.
18. Something I really miss doing since I was diagnosed is: go for long walks alone.
19. It was really hard to have to give up: my dreams.
20. A new hobby I have taken up since my diagnosis is: crafting.
21. If I could have one day of feeling normal again I would: have a great day with my husband.
22. My illness has taught me: all about stigma.
23. Want to know a secret? One thing people say that gets under my skin is: "It's just stress."
24. But I love it when people: genuinely ask how I am.
25. My favorite motto, scripture, quote that gets me through tough times is: "Character cannot be developed in ease and quiet. Only through experience of trial and suffering can the soul be strengthened, ambition inspired, and success achieved." - Helen Keller.
26. When someone is diagnosed I’d like to tell them: well I've not been diagnosed with anythign yet except for the BPD which I was just diagnosed with, so I'd like to be on the receiving end of some advice first.
27. Something that has surprised me about living with an illness is: how cruel people can be about judging who is really ill and who isn't.
28. The nicest thing someone did for me when I wasn’t feeling well was: allowing me to whine for a bit.
29. I’m involved with Invisible Illness Week because: I want to teach people about undiagnosed illnesses and mental illness.
30. The fact that you read this list makes me feel: appreciated.

Requirements for the Proper Multiple

Tonight, I was talking on the phone to the organizer of the DID support group I was a member of for two years until I got kicked out for presumably not having DID last May. She guessed my diagnosis correctly, but went on to assume I'd imagined my DID. Well, I'm going to be completely honest here: I have indeed internalized some symptoms that I didn't have before my diagnosis, like the amnesia, but I had known for almost ten years that I had parts when I was diagnosed. Did I imagine the splits when I was fifteen-years-old because I wanted to be crazy, while I'd never heard of DID back then? Well, I don't think so. Of course, whether these emotional states are truly dissociative or not, depends on your perspective. The organizer got to saying incorrectly that BPD and DID have nothing in common. In reality, many people believe DID is BPD with more flair.

The organizer got talking of me quoting books on the furums. Well, that doesn't say anything, does it? Just because I listed the criteria of BPD yesterday, doesn't mean I don't have BPD, right? Apparently, if you want to be authetnic, you're going to have to have made up your own symptom list without any influence from literature. I wonder how this person, who studied psychology at university, did this. Apparently, people who've studied mental disorders in college cannot be diagnosed with a mental disorder themselves.

To air off a bit of steam in a healthy way, I'm going to repost and expand on the list of requirements for the proper DID'er that I compiled after being kicked out of the support group.

1. You can't use jargon like "co-conscious", "inner self helper", etc. if you've not had your diagnoisis forever. This is not supposed to be familiar language to a person just diagnosed.
2. Even if you know you've got parts because you've established a fair amount of communication, you can't walk into your therapist's office saying you experience parts in yourself. In fact, you cannot have obvious dissociative symptoms. According to what I've been told, saying things happen to you but not quite to you, is not appropriate either (which is what I really came into therapy with).
3. You must've gotten into therapy with seemingly irrelevant symptoms like depression, self-harm, etc. Then it's the therapist's duty to figure out you're multiple, but they can't just straight out ask if you experience parts in yourself. On occasion, they can, but you must be completely clueless to the fact that it's not normal.
4. You must have some doubts about your diagnosis, and you must fear that it's all real. If you fear you're fake, you're obviously already a faker.
5. You must not switch too openly or demand switches be acknowledged, cause DID is something that's supposed to be hidden. Keeping the dissociation hidden must be an end in itself. Note that you won't get a diagnosis of DID if the diagnostician hasn't seen you switch.
6. You must want to integrate.
7. You cannot have littles who write properly. You also cannot have littles who write improperly but on the right subforum, cause how are they supposed to know where to write? However, you can't have alterrs write on the main forum either. Why else would there be specific forums for alters?
8. You must recognize just enough of what other DID'ers, who obviously all are not fake, say they experience, but not too much. You must be able to articulate your experiences in your own words, and others determine whether you use your own words.
9. You must have time loss, but how you're supposed to know you have time loss, is unclear. You can't just say you lose time when others come out, cause how do you know? You cannot say you don't remember something when asked, because then obviously you could pretend you forgot. I don't know how a therapist is supposed to realize you lose time if they cannot ask, especially given that implicit memory is often intact in DID, so DID'ers act like they do remember what other identities did.
10. In meetings, you must present as the host (with the birth name) at all times. You must be oriented to the present if you want to participate in meetings. On the other hand, you cannot actually be the person with the birth name, cause that person must've gone to sleep, been gone at an early age or be totally unaware of any others. How are you supposed to come to a DID meeting if you are clueless about other personalities?
11. You must have survived horrific abuse, but in this partiuclar group, you cannot talk about it in meetings. You need to drop the occasional SRA reference to make clear that you are an authetnic survivor.
12. You must validate others' every experience, but you cannot say you can relate.

In short, you're required to have just enough in common with other people in the group to be able to benefit from shared experience, but you cannot recognize too much or it'd be seen as imitating.

Comments on Schema-Focused Therapy

When I was told that I have BPD on Monday, my therapist got talking about maladaptive schemas. She apparently assumed I knew what they are. I had some idea, but did a quck search to find out anyway. They are beliefs about yourself that are maladaptive and that have usually been formed in childhood (although they can be formed later on too) and repeat themselves over and over, thereby influencing your coping mechanisms. The creators of schema therapy list 18 such schemas. The ones that most apply to me are:

• Abandonment/instability: the belief that you will be abandoned by important support people or that the relationship is unreliable or unstable.
• Mistrust/abuse: the belief that other people will aubse, hurt, humiliate, lie to or otherwise take advantage of you.
• Defectiveness/shame: the belief that you are defective, bad, unwanted, inferior or invalid.
• Dependence/independence: perceived inability to handle your everyday responsibilities without lots of help.

That last one is a bit tricky. While I know I'm depenednet, I don't know whether this is entirely due to my beliefs. I mean, overload comes into the equation too. I got a bit pissed when my therapist wrote in my treatment plan that I have a fear of failure and need to realistically learn to take on challenges. As if I'm not trying!

Then my therapist got talking about schema modes. I had some idea of what they were because my former therapist had talked about them when I first disclosed I had parts. Schema modes are the emotional states and coping responses we adopt when faced with life's challenges. I found it interesting that the Schame Therapy Institute says that they can also be seen as dissociative parts. The Institute lists several different schema modes, including the vulnerable child, the punitive parent, the detached protector and of course the healthy adult. I recognized almost all of them, but in fact have more than one of each. Yeah, I'm not going to abandon the DID concept just because it isn't my diagnosis anymore.

Now schema-focused therapy is used to identify and challenge these maladaptive schemas and to reinforce the healthy adult mode. The assessment phase is followed by the change phase, in which clients learn to challenge their schemas and gradually focus shifts from experiential change to behavioral change and preparing for ending therapy. My therapist put in my treatment plan that the current focus would be on learning about origins and continuation of schemas and that I would recognize my coping mechanisms and hopefully be able to shift them in an early stage.

Ramblings on Self-Image and Diagnosis

This afternoon, I was discussing y treatment plan with my psychologist. I heard her saying something about diagnosis and treatment being complicated by a combination of autism with axis II symptomatology. "Axis II," I thought, "that's personality disorders. Have they finally gotten to diagnose me as BPD?" And yes, they have. And instantly the DID and PTSD diagnoses went out the window. Not only that, but BPD, not Asperger's, is my "main diagnosis" now.

What does this mean? I anticipated it for a long time. In fact, I've always doubted the diagnosis of DID. When initially diagnosed, I was too overwhelmed by some of the consulting psychologist's questions to answer them with the nuance they required. Like, the psychologist asked whether we are aware of what happens when another alter is out. I said no, but the real truth is that we could not have known, since if we lost time, we would only find evidence later and not know that an alter had been out unless we'd had soome awareness of that alter.

I have a very unstable self-image, which goes with both DID and BPD. In addition, I need concrete qualifiers for myself, which I theorize could be an autistic feature. This gets me to identify myself not with abstract characteristics like creative, intelligent or whatever, but with the labels I've been given. I've gotten better over the past year or so at identifying myself with neutral labels like crafter and blogger.

At the same time, I still do have characteristics that are more abstract. I am not just an autistic, a crafter and a woman. I am not just a dissociator or a borderline. Yet what I am in terms of these labels, fundamentally impacts how people see my characteristics. Like, borderlines are generally assumed to be manipulative attention-seekers. If I'm seen as manipulative when a vulnerable alter is out, for example, that means my needs won't be listened to. In contrast if I'm seen as vulnerable when I'm manipulating, I won't unlearn to manipulate. Furthermore, my poor self-image may not alter the core of my mental problems - whether that be a drive to manipulate or emotional vulnerability or both or soomething else entirely -, but it sure alters the way I perceive this core.