BORDERLINE PERSONALITY DISORDER
Revised
and with a new afterword by the author
©
2003 John M Rathbun MD
DEFINITION - a pervasive pattern of instability of interpersonal
relationships, self-image, and affect, and marked impulsiveness, beginning by
early adulthood and present in a variety of contexts
HISTORY:
* This diagnosis has been used over the past 30 years to label patients who
get therapists upset.
* BPD has become the most diagnosed and researched personality disorder.
EPIDEMIOLOGY:
* Two or three per cent of the general population are affected
* Most common personality disorder in clinical settings
* Diagnosed in 11% of psychiatric outpatients, 19% of inpatients, and about
half of all personality disordered patients
* Three times as common in women as in men
* Five times more common in first degree relatives of affected persons
ETIOLOGY:
* Well over half are victims of physical and/or sexual abuse
* Dysfunctional family dynamics are common
* Mothers often erratic and depressed
* Fathers often absent or have major character problems
* Early losses are common
* Genetic data implicate constitutional factors
DIAGNOSIS:
* They typically present with dependent behaviors, seeking nurturance,
closeness, and assistance
* Within a therapeutic relationship, they show escalating need for support
* When frustrated, they show rage and devaluation of therapist
* Their relationships are typically unstable, intense, and stormy
* They show extremes of idealization and devaluation
* They may become extremely ill and self-destructive in reaction to fear of
abandonment
* They commonly have other personality disorders, mood disorders, substance
dependence, bulimia, and PTSD
DIFFERENTIAL:
* Compared to cyclothymic and bipolar patients, BPD are more reactive, angry
in reaction to frustration in dependent relationships, with chronic feelings of
emptiness
* Compared to depressive disorders, BPD are more manipulative in their
suicidality and have poorer relationships
* Compared to psychotic disorders, BPD have brief, reactive psychotic
symptoms, not chronic, persistent ones
COURSE:
* Typical BPD emerges in adolescence
* BPD is especially severe around age twenty-five
* About half improve spontaneously in their thirties and forties
* BPD commonly fail in education, employment, and relationships
* Suicide claims eight to ten per cent; many more carry scars of
self-mutilation
MEDICAL TREATMENT:
* Selective serotonin reuptake inhibitors and mood stabilizers help impulse
control and moodiness
* Antipsychotics help ideas of reference and brief psychotic symptoms
* Benzodiazepines and mood-altering chemicals make things worse
PSYCHOTHERAPY:
These are difficult psychotherapy patients. They have a lot of turbulent
emotion in relation to the therapist, and they act out in ways that endanger
them and irritate the therapist. Therapists are tempted to reject or indulge
BPD.
It often takes five or more years of intensive individual psychotherapy to
resolve BPD.
The therapist must be consistent and reliable, with excellent boundary
management.
These patients routinely induce splitting in treatment teams.
They will not progress in therapy if currently being abused; they may
under-report or over-report abuse.
These are not cases for the beginner, and student therapists should have
intensive supervision when working with borderlines.
A DYNAMIC FORMULATION:
Ego States Theory was developed to explain why some adults intermittently
behave like children. According to Ego States Theory, we all start out life as a
collection of unintegrated ego states, such as "Happy baby",
"Hungry baby", "Scared baby", "Mad baby", and
"Sleepy baby". We observe normal infants making abrupt switches
between these ego states according to their current circumstances, and there
seems to be little continuity of memory from one such ego state to the next. We
observe normal parents sponsoring integration of ego states in normal
youngsters. The preschooler who falls and hurts himself while playing undergoes
a switch from the "Happy child" ego state to the "Scared and
painful" ego state, and seems to have no idea that his suffering is a
temporary condition. Mother provides reassurance along the following lines:
"You're OK now, even though it hurts; you were happy a few moments ago,
and you'll be happy again in another few minutes!" We can later observe
the same child in grade school getting hurt, starting to switch ego states, and
then reassuring himself that he'll feel better soon, thereby maintaining his
own ego integration. In adulthood, the fabric of ego integration is usually so
tightly woven that it takes a catastrophe to cause dissociation of ego states.
Some children, however, don't have a "normal" childhood with the
support of well-integrated parents. Suppose father is alcoholic: he may come
home drunk and rape the little girl, and the next day he may not remember what
he did. Mother may be physically or psychologically absent from what's going on
with her daughter, so father is her only source of comfort. The child may be
unable to get help for a variety of reasons, including her fear of father, fear
of losing her father, and a sense that what's happening is inevitable. She
faces an endless series of irreconcilable realities.
Her best defense may be to maintain two distinct ego systems, one of which
deals as best she can with father the rapist, the other with everyday living.
The defense of dissociation permits the child to avoid thinking about the abuse
so she can have as normal a life as possible.
When this sort of childhood starts early and goes on a long time, the ego
states may accumulate very different memories, emotions, and behaviors. They
may even have different names for themselves: one name representing the angry,
hurt, sexually aware part, and the other designating the innocent child in her
public persona.
A child growing up in a very sick family system faces a large number of
insoluble problems, and dissociation may become the preferred way to deal with
virtually every conflict the child faces. Thus, a system of dissociated ego
states may arise, one of which does well in school, another is very athletic, a
third feels a great deal of rage, a fourth can function sexually, and the fifth
goes to church and prays a lot - thus fully expressing all the family values in
one person without having to resolve any of the conflicts that divide the
family.
Most borderlines report growing up in family environments that were
UNSAFE - abusive, threatening, unstable
DEPRIVING - rather than nurturing
HARSHLY PUNITIVE - often following inconsistent or invisible rules
SUBJUGATING - punishing child's normal expression of needs and feelings.
Therefore, the borderline patient may usefully be viewed as a collection of
relatively unintegrated ego states, whose dysfunctional behaviors and emotions
constitute the presenting signs and symptoms. They differ from DID in that
complete amnesia between ego states is not seen in BPD as in DID. They differ
from PTSD in that intrusive recollections are less prominent in BPD than in
PTSD. However, there's considerable overlap in the origins, signs, symptoms,
and effective treatment paradigms for DID, PTSD, and BPD; if you are successful
with one of these groups, you'll likely do well with the others.
I find ego states theory helpful in understanding dissociative disorders,
PTSD, and BPD. Ideas about dissociation have become very controversial,
however. Many psychologists are strongly opposed to the idea that traumatic
memories can be lost and then reemerge. I find these criticisms ignorant,
corrupt, and absurd.
They are ignorant in that they persistently confuse dissociation and
repression in statements like, "There's no evidence for repressed
memories!" DISSOCIATION is a theory introduced by Pierre Janet, who
observed patients with various sorts of hysterical illness to be cured when
they recalled traumatic events that were symbolically connected to their
symptoms. Janet's work came before that of Sigmund Freud, who initially
endorsed Janet's ideas, then proposed his own theory of REPRESSION. What is
repressed in Freud's theory is a girl's unacceptable wish: to replace mother as
father's love object. This wish is both denied and gratified in a SCREEN
MEMORY: that father initiated sexual activity with the child. In other words,
REPRESSION leads to remembering trauma that never happened, while DISSOCIATION
is the forgetting of trauma that DID happen. Any so-called expert who confuses
these two antithetical theories is not worthy of serious attention.
Many of the critics of dissociation are corrupt, in that they are associated
with an organization that exists mainly to assist persons accused of sexually
abusing their children to escape prosecution.
Finally, criticisms of dissociation are absurd, in that they allege that
memory is fallible in only one direction. They claim that real trauma can never
be forgotten, but that overzealous therapists often create memories of trauma
that never happened through their suggestive techniques. These concerns are
based on a small number of cases studied by one particular psychologist who
observed contrived situations with little relevance to clinical reality.
The "recovered memories" controversy is heated and serious in its
implications; it's well for therapists who treat trauma victims to be keenly
aware of the major issues being debated, to avoid hypnotic and other suggestive
techniques, and to steer clear of prosecutions based on recovered memories
unsupported by other convincing evidence.
THERAPEUTIC TECHNIQUES:
The basic techniques that have been found useful in dissociative psychopathology,
whether PTSD, BPD, or DID, emphasize the following common therapeutic factors:
1. Development of continuity of memory across ego states leads to improved
integration of behavior, affect, sensation, and knowledge
2. A more thoughtful approach to decision making should replace
dysfunctional behavior patterns which are impulsive and emotionally driven
3. Appropriate expression of affect is facilitated in a therapeutic setting,
with attention to parallel development of a repertoire of healthful self-soothing
behaviors
4. The patient is encouraged to experiment with new patterns of behavior
which will be more effective in getting the patient's legitimate needs met
5. The patient is given the opportunity to use the therapist as a role model
for a healthier adult lifestyle.
To assist the therapist in maintaining appropriate engagement with
borderline patients, a psychologist at Columbia
named Jeffrey Young has developed an interesting way of categorizing the ego
states commonly seen in borderlines. In his experience, the borderline patient
will normally present four ego states, which he calls MODES:
1. The patient normally presents for therapy in an ego state which Young
calls The Vulnerable Child Mode - in this mode, the patient is compliant and
seeking assistance. This is a continuation into adulthood of behavior patterns
used by most children to secure caring and assistance from powerful adults. The
therapist will be idealized by the patient in this mode, often leading to a
breakdown in normal therapeutic boundaries if the therapist's grandiosity or
guilt can be hooked by the patient. Since the borderline's need for emotional
nurturance exceeds the capacity of even the most giving therapist to satisfy,
the therapist who lacks good professional boundaries will often begin to
experience anxiety and resentment about the patient's escalating demands. This
will cause a failure of empathy on the therapist's part, leading to the
emergence of
2. The Angry Child Mode - in which the therapist is harshly devalued by the
patient. If the therapist reacts defensively, an even more dysfunctional ego
state will emerge:
3. The Punitive Parent Mode - since the child was punished for expressing
normal needs and emotions, the adult knows that she is wrong to have these
needs and emotions, and deserves punishment for expressing her feelings.
Because she has internalized her parents' dysfunctional attitudes and
behaviors, she will begin to punish herself for having needed the therapist so
much, and for having expressed her anger at the therapist for not satisfying
those needs. In the punitive parent mode, the patient will derogate herself
during internal dialogues, will experience herself as defective, worthless, and
contemptible, and will often punish herself through self-mutilating or
self-poisoning. Her attempt to regain a position of emotional equilibrium will
often lead to the fourth and last of the common ego states seen in borderlines:
4. The Detached Protector Mode - in which feelings are disavowed, and the
patient appears passively compliant and placid. This particular ego state is
often overvalued by naive therapists whose personal insecurity leads them to
prefer the appearance of calm to the turbulence of the patient's other ego
states.
The Detached Protector Mode is actually the least workable of the four ego
states commonly seen in borderline patients; the only appropriate therapeutic
technique for this mode is to encourage the Vulnerable Child mode to reemerge.
One can do this by reminding the patient how she felt in a previous session.
You may then have to work through eruptions of the Punitive Parent Mode by
assuring the patient that her need for nurturance is normal and acceptable. In
general, your goal is to extinguish the Punitive Parent Mode by presenting
yourself as a more accepting and appropriate parent for the patient.
The Angry Child needs help learning how to express that emotion in
nondestructive ways. A therapist who is personally secure will encourage the
patient to verbalize even more anger at the therapist, but actual verbal abuse
should be redirected into more authentic emotional expressions. In this regard,
the patient can be helped to use "I" statements rather than "you"
statements - "I felt abandoned by you" rather than "You're a
cold, uncaring, heartless bastard". You may have to assist the patient to
understand that "I think you're a cold, uncaring, heartless bastard"
is really a "you" statement disguised as an "I" statement.
The payoff for the patient in learning how to verbalize anger more
appropriately is that the patient can then be angry without sacrificing
connection with potential sources of emotional nurturance.
The Vulnerable Child Mode is the most workable ego state in borderline
patients. Young suggests four basic techniques for this ego state:
1. Cognitive interventions - using journaling, you can teach the patient to
examine her dysfunctional thoughts and decide for herself if they are valid.
Some common dysfunctional assumptions in borderlines are
a. The world is dangerous and wants to hurt me
b. I am powerless in this world
c. I am hopelessly defective
d. Things are good or bad, choices are all or
nothing
2. Experiential techniques - such as gestalt, imagery, and inner-child work
3. Therapeutic relationship - giving the patient a good example to imitate
4. Behavioral pattern breaking - finding new and more effective ways to get
legitimate needs met
Some basic therapeutic techniques to
use with borderlines:
1. Validate needs and feelings; avoid problem-solving for the patient
2. Be reliable and caring and real
3. Strongly praise any improvement in behavior
4. Re-attribute parental rejection to parental defects
5. Teach the patient to recognize the various ego-states or modes of
behavior as they emerge in the sessions, and to understand how their
dysfunctional assumptions arose naturally from their suboptimal early
experiences
6. Attribute any patient failures to the patient's excusable
misunderstandings and help the patient to analyze these
7. Using the empty chair technique, teach the patient how to talk back to
the punitive parent
8. Acknowledge your mistakes and model forgiveness of yourself and others
Most therapists who write about treatment of post-traumatic syndromes
emphasize that treatment must proceed in stages. The first stage is always
focused on the development of a therapeutic relationship based on mutual
understanding and respect. Young suggests this stage will be facilitated if the
therapist can always think of the patient as a needy, primitive child rather
than as a greedy, manipulative opportunist. Emergence of such negative
attitudes in the therapist is associated with poor treatment outcomes, as the
patient's original experience with a punitive parent is repeated in the
therapy.
It is important that patient and therapist agree on goals for the treatment
in language that makes sense to the patient. It will also be necessary for the
therapist to make clear the limits of therapist availability. Most patients
with BPD have daily and nightly emotional crises, and will need frequent
reassurance by phone or in extra sessions, at least until they learn how to
manage their emotions better. It's legitimate to tell the patient that daily
phone calls are not OK, and that late night calls make you cranky the next day.
You can also mention that learning self-soothing is one of the important goals
of therapy.
If the patient is doing something that you can't tolerate, it's important to
discuss this in session before you reach the point of resenting the patient.
It's appropriate to tell the patient that frequent phone calls disrupt your
personal time and that you may begin to feel resentful if it continues.
Borderline patients have usually grown up around people with poor conflict
resolution skills and poor interpersonal boundaries, so you want to show the
patient how two adults can discuss and resolve a conflict without becoming
abusive or withdrawn from each other.
When your practice situation permits, it's appropriate to inform the patient
that you charge for after hours phone contacts as well as for extended phone
contacts during office hours. These are professional services which the patient
should expect to pay for, just as you would expect to pay for the furnace man
to come and relight your burner on a cold winter's night. Offering unlimited
free support at all hours of the day or night is a recipe for therapist burnout
and for a major betrayal of the patient's trust, because you will not be able
to keep it up, and a burned-out therapist is both unhappy and dangerous.
Since many of you work for not-for-profit agencies, let me take a moment
here to disparage certain dysfunctional attitudes that seem to pervade such
organizations. You probably went into this sort of work because you enjoy
helping people, and you feel real compassion for those less fortunate. These
traits make you willing to work long hours for low pay, and your professional
reputation depends on your willingness to go the extra mile for your clients.
When an entire organization is staffed from top to bottom with professionals
who share the value of self-sacrifice, there's an opportunity for the best
intentions to lead to the worst outcomes.
Not only does your borderline patient need to see that relationships can
have limits and still be rewarding, she also needs to believe that she can
survive on her own adult resources in this world. The therapist who can't limit
the patient in her quest for constant reassurance is saying, "Yes, you
really are just as incompetent as you feel!"
The most challenging aspect of therapy with BPD is knowing how to set and
enforce limits. This is a matter of therapeutic art, and cannot be taught in a
lecture or manual. We all make errors in judgment when it comes to enforcing
limits and providing optimal levels of support in therapy. More experienced
therapists are less likely to make these errors, and should be sought as
mentors by less experienced therapists. Therapeutic technique is not perfectible,
only subject to endless improvement. Borderlines are those patients who show us
where we have room to grow in our technical skills.
Important areas for limit setting in
BPD:
1. Rules for outside contacts
2. Abusive behavior in sessions
3. Client must agree to attend one more session before quitting (implies no
impulsive suicide)
4. Missed sessions must be planned (charging for no-shows and late cancels,
except in extraordinary circumstances, is good for the patient)
5. Patient must contact therapist before destructive acting out
6. "If you make me hospitalize you involuntarily, I won't work with you
after discharge"
Note that the threatened loss of the therapeutic relationship, once
established, is the most potent adverse consequence available.
Dealing with the borderline in
crisis:
a. Find out what mode they're in and respond appropriately
b. Increase visits, even a few minutes every other day can help
c. Assess suicidality: plan, intent, timetable, available means, any steps
taken, past history, substance abuse
d. Get permission to talk to significant others and arrange increased
support
e. Consult with another professional and document it
f. Consider referral for medical therapy
g. Consider day hospital or support group
h. Consider brief hospitalization
If you're interested in a more complete protocol for the treatment of BPD,
and one with some actual outcome research to recommend it, you should look at
two books published in 1993 by Guilford Press, both written by Marsha M
Linehan: Cognitive-Behavioral Treatment of Borderline Personality Disorder, and
Skills Training Manual for Treating Borderline Personality Disorder. Linehan's
method is briefly outlined in Guilford's Clinical Handbook of Psychological
Disorders.
Linehan calls her method Dialectical Behavior Therapy because she
emphasizes training the patient to abandon simplistic ways of thinking. She
correctly points out that reality is complex and multifaceted, and that we all
have to deal with situations involving conflicting and ambiguous data. An
overall therapeutic goal of Linehan is to teach the patient to avoid rigid
thinking and extreme behavior.
Linehan emphasizes that the therapist must respond hierarchically to the
many challenges presented by borderlines. Suicidal behaviors have the highest
priority for therapist attention, followed by therapy-interfering behaviors,
then quality-of-life interfering behaviors.
Important behavioral skills taught in
Linehan's method:
1. Distress tolerance (desensitization, using the therapist to reduce
anxiety)
2. Emotion regulation (including affect identification and management)
3. Interpersonal effectiveness (conflict resolution and empathy)
4. Self-management (learning how to increase chances of success in meeting
ones goals)
5. Mindfulness (non-judgmental awareness)
These skills can be taught in individual sessions, but it's more
cost-effective to offer weekly didactic groups to teach basic skills while the
individual therapy focuses on the problem areas most relevant to the particular
patient.
Both Linehan and Young, in common with most therapists who work with trauma
survivors, delay dealing with traumatic memories until the patient has
sufficient trust in herself and in the therapist to withstand the high levels
of emotional arousal that commonly accompany a focus on past trauma. It may
require many months of preparation before a patient can reliably resist
self-destructive impulses, maintain a stable lifestyle, and show significant
progress in the basic skills addressed in Linehan's Stage I.
Skillful treatment of PTSD is a complex, challenging, and contentious area.
The basic goals are:
1. Remembering and accepting the facts of earlier traumatic events, or
learning to live with perpetual uncertainty about what actually happened; and
2. Reducing stigmatization and self-blame
Arthur Freeman chairs the psychology department at the Philadelphia College
of Osteopathic Medicine and also directs the Cognitive Therapy Training Program
at the Adler School of Professional Psychology in Chicago. Among his many
relevant publications is a book called Cognitive Therapy of Borderline
Personality Disorder.
At a recent symposium on BPD, Dr. Freeman gave some pointers on here-and-now
focus in the treatment of PTSD. In his view, "The preferred intervention
is the least intensive, least extensive, least intrusive, and least costly
alternative that will provide what the patient requires at that time."
Focusing on Cognitive treatment of intrusive recollections and flashbacks,
Freeman suggests the therapist's initial focus should be on assisting the
patient to precisely characterize the experience so as to make it more concrete
and less eerie for the patient. He asks for
1. A complete description of the thoughts or perceptions which constitute
the episode;
2. Identification of anything in the current life situation which may have
triggered the episode, with specificity as to the particular aspect of the
current situation which was a trigger;
3. A description of emotions, thoughts, sensations, and behaviors which
followed the episode.
Dr. Freeman's approach shares with the majority of therapists working in
this area the basic technique of converting emotions into words, which seems to
assist the patient in gaining a sense of mastery over the strong emotions
involved. He also encourages journaling for this purpose, and teaches
relaxation and imagery as tools for self-soothing.
Traumatic nightmares are handled similarly to flashbacks; writing down the
nightmare upon arousal is useful because some of the most important images will
not be remembered the next day. Freeman emphasizes reinforcing the patient for
gaining control over the intrusive recollections.
With reference to the specific problem of flashbacks which occur during
sexual activity, Dr. Freeman suggests that sexual activity be interrupted until
both partners are comfortable with its resumption; to close one's eyes and wait
for him to finish would tend to reinforce dissociation through reenactment of
the trauma. Communication with the partner about what's happening is
encouraged, as is asking for the partner's support. The patient can also train
herself to pay attention to important differences between the current partner
and the original perpetrator, including both differences in appearance and
differences in the quality of the relationship. In some cases, the partner may
need professional assistance to become more comfortable with the patient's
special needs; in others, the problem in need of attention may be the patient's
inappropriate choice of partner.
Linehan's third stage puts appropriate focus on the patient learning how to
maintain improvement without so much help from the therapist. Goals of this
stage are:
1. Non-defensive self-appraisal that will resist unreasonable attacks on
one's self-esteem; and,
2. Trust in one's ability to cope with stress.
In her discussion of telephone contacts between sessions, Linehan emphasizes
the need to repair the relationship. Borderline patients often experience
delayed emotional reactions to something the therapist said or did during a
session. Often, the next call after a session relates in some way to such a
delayed reaction. The therapist’s ability to accurately hear the underlying
concern and to respond with empathy can substantially improve the chances for
the patient to stay in therapy. Arthur Freeman suggests that each session end
with an invitation for the patient to give the therapist some feedback, thus
reducing the probability of rumination and after-hours phone calls.
Linehan characterizes the skillful therapist as "able to balance a high
degree of nurturing with benevolent demanding." This is one of a number of
paradoxical elements of the therapy situation to which she refers in her
writing. Others are
a. Clients are free to choose their own behavior, but they cannot stay in
therapy if they do not work at changing their behavior.
b. Clients are taught to achieve greater independence by becoming more
skilled at asking for help from others.
c. Clients have a right to kill themselves, but if they ever convince the therapist
that suicide is imminent they may be locked up
d. Clients are not responsible for being the way they are, but they are
responsible for what they become
Such paradoxical elements can be presented to a patient at the appropriate
time and in an appropriate manner, to stimulate reflection and to help the
patient move beyond simplistic thinking. Linehan also recommends skillful use
of metaphor, stories, parables, and myth in therapy. These techniques require a
certain literary bent and much skill to apply; their strength is that they
circumvent the patient's logical resistance to new ways of thinking about the
world.
Another advanced therapeutic technique recommended by Linehan, and
applicable in any therapy, is to take the patient's absurd position and
logically extend it until even the patient sees the absurdity. This has to be
done with exquisite sensitivity or the patient will feel mocked. Two examples
cited by Linehan are:
1. The patient would rather die than gain weight; if being dead is
preferable to being overweight, the overweight therapist is within reason to
offer to join the patient in a suicide pact.
2. The patient will kill herself if the therapist won't see her immediately;
the therapist expresses great anxiety and offers to call an ambulance so the
patient can be hospitalized for her own protection.
These are tricky techniques, in which the therapist both joins with the
patient and proposes a therapeutic ordeal.
Linehan's method, like Young's, emphasizes the therapeutic relationship as
the ultimate reinforcer of patient behavior. It is essential that the therapist
pay a lot of attention to the patient's progress and minimize attention to
negative behaviors. The therapist may find herself in a dilemma when it comes
to responding adequately to the patient's self-destructive behaviors without
reinforcing them. It may be helpful to frankly share this dilemma with the
patient.
In her discussion of limit-setting, Linehan stresses that the therapist must
understand the limits of his or her own tolerance for the patient's bad
behavior, and clearly communicate this information to the patient.
"Therapists who do not do this will eventually burn out, terminate
therapy, or otherwise harm the client." She suggests the therapist be
frank and unapologetic about some limits being for the good of the therapist.
Linehan chooses to instruct her patients that cognitive distortions are
frequently a consequence of emotional arousal. This is a departure from a
purely cognitive framework, in which dysfunctional cognitions are seen as the
cause of turbulent emotion. None the less, Linehan shares with therapists all
the way back to Sigmund Freud the basic idea that pausing for rational analysis
is better than allowing one's rawest emotions to govern one's behavior. She
also shares with most mainstream therapists a preference for techniques which
encourage the patient to desensitize herself to the fear of emotion by
repeatedly experiencing these emotions in the therapy sessions while the
therapist assists her to delay any behavioral response.
In her discussion of therapist style, Linehan suggests that the therapist's
negative emotional reactions to the patient can be used to educate the patient
about her impact on others. For example, "When you demand warmth from me,
it pushes me away and makes it harder to be warm." I'm a bit uncomfortable
with this intervention because it contains embedded YOU statements: "you
demand... you push me away...." A more authentic statement might be,
"Sometimes I feel more distant from you at the very times when I sense you
wanting me to show warmth to you. I wonder if others around you sometimes have
the same response, and if there's anything you could do differently to increase
the chances of getting the response you want."
Linehan also recommends the therapist try to stay in a
consultant-to-the-client role, except when the patient is clearly overwhelmed.
This helps to avoid infantilizing the patient, and also helps the therapist to
avoid being sucked into confrontation with others over what's "best"
for the patient.
It's important to remember that you can't save every patient, especially the
chronically suicidal ones, without locking them up for several years at a time.
This means that if you don't have the strength to bear the loss of an
occasional patient to suicide, even the ones you really care about, you
shouldn't be in this business.
When you do lose one, it should be a learning opportunity. You as therapist
should insist on case consultations from consultants chosen for their expertise
rather than for friendship. This process is scary, but also uniquely growth
promoting.
CONCLUDING REMARKS:
In summary, Borderline Personality Disorder is one of the most challenging
entities for today's therapist; in fact, this category originated as a
repository for patients who fail to improve with ordinary treatment methods and
whose particular pathology is most likely to provoke a negative emotional
reaction in the therapist. Comfort and effectiveness in the treatment of BPD
implies mastery both of one's own emotions and of therapeutic techniques in
general. It is not realistic to expect success in every case, and successful
treatments are usually long and stormy.
Borderlines ARE treatable. Linehan's study of 44 severely affected women,
treated over one year with either Dialectical Behavior Therapy or
"treatment as usual", showed an attrition rate of only 17%, with
reductions in frequency and severity of self-injury, and fewer hospital days
for the patients treated with DBT. A second study showed improvements in anger
management, social adjustment, work performance, and anxiety with DBT. These
results were maintained at 6 and 12 month follow-ups. The original study was
published in the Archives of General Psychiatry, vol 48(1991) pp 1060 ff.
The major open question is whether current restrictions on payment for
psychotherapy will permit many borderlines to have effective treatment. No
satisfactory brief therapy for BPD has been reported. In many settings, the
best we can hope for is to deal with a series of crises in ways that may have a
favorable cumulative impact on the patient. We must assist borderline patients
to get their emotional needs met without their having to resort to grossly
self-destructive behavior. The current tendency to provide acute medical
treatment and outpatient referral rather than inpatient admission, and to keep
inpatient stays very short, may actually be helpful in this regard, because it
avoids reinforcing the patient's dysfunctional behavior.
Afterword
I’m gratified that these lecture notes have found a wider
audience, and been adjudged helpful by so many readers. One such reader is the
facilitator of a self-help website who asked me to deal in more detail with
borderlines who don’t recall any traumatic incidents sufficient to explain
their symptoms.
In this regard, I want to emphasize that maladaptive
behavior patterns rarely have simple, single causes, and that circular
causation is distressingly common in psychiatry. This truth is expressed in the
bio-psycho-social theories that dominate most informed discussions of etiology:
that an individual’s brain is constructed with certain innate proclivities that
arise from genetic inheritance as modified by intra-uterine influences, and
that everything that happens after birth influences the individual’s
characteristic patterns of perception and reaction. Current events commonly
serve as triggers for behaviors that may be unexpected and self-defeating,
creating in the observer the perception of “mental illness”. Such dysfunction
is no more “mental” than alcohol-withdrawal delirium, since behavioral habits
involve changes in the brain’s wiring and chemistry, known to neuroscientists
as “long-term potentiation”. Investigation of such behaviors, from the clinical
perspective, must focus on finding the most cost-effective interventions that
will safely disrupt cycles of sickness, the emphasis being more on sustaining
than on initiating factors.
To address the specific issue of patients who meet criteria for
BPD but lack history of sufficient early trauma, several possibilities occur:
- Misdiagnosis: Calling a person
“borderline” doesn’t make her one. This diagnosis should be given by a
well-trained clinician, preferably at the doctoral level, after a careful
personal examination of the patient. Popular descriptions of psychiatric
problems in the lay press and on the Internet may encourage amateur
diagnosis of self and others, often to the confusion of all.
- Genetic factors: As mentioned
above, data suggest there are inherited genetic factors which may increase
the probability of borderline personality dynamics. A persistent myth of
modern American culture is that human nature is infinitely malleable. In
fact, studies of children who are adopted away at birth show that decades
later their personality resembles the birth parents they’ve never seen
more than the adoptive parents who raised them. Genetic factors are known
to be implicated in many types of emotional instability, and some genetic
material may require no environmental assistance to manifest as serious
psychiatric illness.
- Abuse has occurred but is not recalled
or not reported by the patient: For those who still can’t believe this
ever happens, I recommend the excellent article at http://www.jimhopper.com/memory
- Cortisol toxicity: Data suggest
that maternal over-arousal floods the fetal brain with a stress chemical
called cortisol, which is known to damage the brain, impairing emotional
stability for decades afterwards. A child’s own emotional stress can also
flood a developing brain with cortisol. The latter is a postulated
mechanism for acute and chronic post-traumatic stress syndromes, to which
youngsters are more vulnerable than adults. Children are notoriously
sensitive to their mothers’ emotions. A child whose mother is chronically
or repeatedly severely overanxious may thus be exposed to a double dose of
cortisol poisoning: mother’s cortisol zaps her before birth and her own
cortisol afflicts her thereafter.
Implications:
- Diagnosis
in psychiatry is not a game for well-meaning amateurs.
- The
best defense against illness is to carefully choose one’s parents.
Practical application of this insight awaits further development.
- Many
persons come to therapy with accessible memories of abuse which they have
suppressed to the point of not making obvious connections between present
distress and past suffering. Rarely, such memories may be temporarily lost
to conscious recall, or may exist in preverbal engrams which are
inaccessible to narrative reconstruction. Then latter cases present
extreme diagnostic and therapeutic challenges, not least because such
persons are often so suggestible that excavation of the past inevitably
destroys its roots or, at least, severely compromises its authenticity. In
many such cases, it is difficult to avoid reinforcement of intriguing
fantasy material by the therapist’s selective attention. As a general
rule, all patient productions should be regarded as hypothetical
constructs whose real meaning can be understood after considerable time in
therapy, if at all. Learning to live with uncertainty about what really
happened is a vital part of the therapist’s character, and may also be an
important therapeutic goal for the patient.
- Contrary
to our wishes, some things get broken and can’t be fixed. In such cases,
appropriate use of psychotropic medication may make the difference between
a life of unbearable suffering and one that has room for moments of
achievement, love, and joy. Puritanical attitudes and quackery should not
be allowed to stand between a suffering person and lasting recovery.
& copy 2003 John M Rathbun, M.D.
