Borderline Personality Dynamics: the Role of Self-Normalization

“By its very nature, the act of remembering is to offer a thing of patches, to try to put together again a once seamless garment of events totally and immediately experienced but now tattered by time.”

Herbert O’Driscoll

Borderline Personality Dynamics: the Role of Self-Normalization

TISA Description of the Problem: In “Psychiatric Interviewing: the Art of Understanding, 2nd Edition (1998)”, I introduced into the clinical interviewing literature the term “normalization” as a type of “validity technique”. When using normalization the interviewer metacommunicates that it is safe for the interviewee to share a sensitive or taboo topic by indicating that the interviewer has heard it before from other clients. A common use of normalization is in the raising of suicidal ideation as follows, “Sometimes when people are feeling as depressed as you’ve been feeling, they find themselves having thoughts of killing themselves. Have you been having any thoughts like that?” A variant of normalization is “self-normalization” in which the clinician uses himself or herself as the reference point. I first learned about self-normalization from a talented pulmonologist, Ed Hamaty, D.O., who specialized in helping patients afflicted with AIDS. Many of these patients had a hard time breaking through their own denial about the implications of the disorder (this was before the appearance of our newer medications that are so helpful. At that time AIDS was basically a terminal diagnosis). To help them cope with their emotions and fears he would say to patients whom he knew well, “Jim, I know if I had learned that I had a serious diagnosis like cancer or AIDS I would find myself having all sorts of different feelings from anger to fear to sadness. I’m wondering what kinds of emotions you’ve been having.” Self-normalization can be quite effective, especially when well-timed. Note that self-normalization is not the same as self-transparency (where a clinician shares a bit of information from his or her own life). In self-normalization the interviewer never shares personal information, instead, the phrasing is either first-person singular in an imaginative sense as with, “I know if I . . . . ” or is first-person plural in a generic sense as with, “We all can have moments of self-doubt, I’m wondering if you . . .” At a recent set of workshops I provided in Brandon, Manitoba, Canada, a participant, M. Faye Wirch, MD, CCFP, FRCP, shared the following clinical interviewing tip. It is a very insightful way of using self-normalization to raise suicide in patients that often can be difficult to engage and can be easily offended.

Tip: When I am working with a patient with borderline personality disorder, I find it helpful to use self-normalization as opposed to simply using normalization. So, for example, if I might want to ask about suicidal ideation I might say:

“You know, all of us, when we are feeling over-loaded or over-stressed and feeling like we can’t bear anymore, can have thoughts about killing ourselves from fleeting thoughts to more persistent ones. I’m wondering have you been having any thoughts about killing yourself?”

My thought with patients with borderline personality disorder is that this use of self-normalization (as opposed to classic normalization) makes suicidal ideation appear as part of the human experience as opposed to just something that “crazy” people or psychiatric patients think about. I find it very powerful coming from me, as a psychiatrist, because it gives the message that not only can humans have these thoughts but even mental health care-givers (psychiatrists, psychologists, social workers, nurses, care-mangers, etc.) can have had these thoughts.

TISA Follow-up: Here is an outstanding example of a clinical interviewing tip that is both sophisticated and practical at once. M. Faye Wirch is carefully using a self-normalization. Note that there is no self-disclosure here. Instead, she is using a generic plural (we) that metacommunicates quite effectively that the client is not alone in having suicidal ideation and that such thoughts can be seen in all walks of life including mental health professionals.

Tip provided by:

M. Faye Wirch, MD, CCFP, FRCP
Brandon, Manitoba, Canada