If I got a quid for every time someone mentions tough love as an approach to helping, or probably more accurately ‘dealing’ with, a person with BPD, I could fund life-saving DBT programmes that by the way, do not take this approach. But before I discuss this concept, we obviously need to define it. ‘Tough love’ essentially implies being very strict to someone to help them overcome their problem, enforcing constraints on them. This is generally said to promote responsibility. Although DBT, one of the main treatments for BPD, does not use this concept, other therapies do. I deliberately decided against a referral to CAT after my CPN told me that every relapse meant I would be punished and could not receive sessions for a period of time. I somehow doubt this is specific to CAT because there a lot of CAT therapists who I have never heard using this method but in my trust, that seemed to be the way. Anyway, ignoring that under these circumstances I would have maybe seen my therapist once a year or probably never at all, I was too disappointed in the concept in the first place. What I needed was someone to teach me crisis skills, someone to finally understand, not another environment I did not feel safe in.
I personally believe that the concept of tough love can be damaging to people with BPD. Yes, I am all for taking responsibility and learning how to deal with life’s up and downs in a healthy way, but I don’t see how negative reinforcement is going to help with that. BPD is a result of invalidating environment(s), often complex trauma and growing up feeling unsafe. That does not have to be physically, that can be emotionally, too, which research has shown to be just as detrimental. For someone with BPD, the world feels like an unsafe place. So do we really need another relationship where we are afraid to be who we are for the fear of getting punished? Another relationship where the other person clearly holds the power? To me, the concept of tough love is somewhat connected to the assumption that people with BPD are ‘just acting out’, just trying to get attention, like a toddler throwing a tantrum. What people, and sadly a lot of professionals, don’t see is the immense pain that is driving these behaviours. Problematic behaviour in BPD may the only way that we know to express our inner emotional turmoil, the only way we can feel in control in a world that feels so out of our hands. A world where people randomly leave, a world where people randomly stop loving you, a world that has threatened your personhood, leaving you to pick up the pieces of the jigsaw puzzle.
So does it make sense to punish a person for the behaviour that has helped them survive? A behaviour that may be effective despite being maladaptive? Had I done the CAT therapy suggested, I fear that my risk would have increased because these coping strategies that seem damaging have kept me safe and given me a way to deal with day to day life. Only when they stopped working did I feel like someone had entirely pulled the rug from under my feet. Also, many of my ‘problematic’ behaviours are grounded in perfectionism, an inability to allow myself to mistakes. This feeling stems not only from my ambitious character but also from friendships where a single word could suddenly lead to the end of it, even if no harm was intended. So if you ask me, a lesson that people with BPD benefit from immensely is that it is okay to make mistakes, okay to try to better yourself, okay to take 5 steps forward and 2 steps back. What people with BPD need is a safe environment in which we can flourish, not another alliance based on fear of doing something wrong.
Don’t get me wrong. Taking responsibility for my own actions has been vital in my road towards recovery. In DBT, I have learned not to blame and that I am solely responsible for my actions. And yes, setting boundaries has been incredibly important in my therapeutic relationship but I get to try that out in a safe and validating environment which is making me slowly lose my fear of sticking up for myself. Whilst I believe it is important not to positively reinforce at risk behaviour by e.g. only speaking to a person after an incident happens, only caring about someone when they are in hospital, only believing them after things have reached crisis point (looking at you, community mental health teams), making sessions longer if the person has self-harmed (unless required for risk management obviously), I fail to see how negative reinforcement can help someone who has gone through that all of their life.
Instead of practicing tough love, I think it is crucial to get to the root of at-risk behaviour, work on alternatives and also validate the coping mechanisms that have helped us survive. As I am often reminded in DBT, we are all doing the best that we can.
What is your opinion on the concept of tough love, both for BPD and other mental illnesses? Do you think it is useful or damaging? Or somewhere in between?