Receiving a diagnosis of borderline personality disorder (BPD) may seem devastating. There’s a lot of confusion about what BPD really means and how it’s actually treated.
Along with misunderstanding, there’s also stigma — and not just from other laypeople, but also from professionals. This can make a person feel even more alone. However, BPD actually affects about two percent of the population. That’s more people than have bipolar disorder or schizophrenia. And there’s good news: Borderline personality disorder is treatable and recovery is possible. Here’s a closer look at everything from what BPD really looks like to how it’s treated to what loved ones can do.
- Individuals with BPD are manipulative. BPD is the result of a combination of causes, including biological factors and a history of being invalidated, which may result in an inability to regulate emotions, according to Michael Baugh, LCSW, an expert in dialectical behavior therapy (DBT) and mindfulness at Third Wave Behavioral Center, his private practice in Seattle. Picture a bell curve of emotionality, Baugh suggested. “Individuals at the more emotional end of the spectrum (like people with BPD and many good therapists) are more easily and strongly triggered by events in their environment, and it takes longer for them to return to baseline — but they can learn the skills to manage these more intense emotions,” he said.Baugh gave the following example: An emotional child grows up in a stoic family, where he’s constantly told to calm down. He tries to follow the family’s rules by suppressing the awareness of his emotions. As the intensity of his emotions ramps up, however, it eventually bursts out of the zone where it can be ignored. When this happens, the emotions appear to go from zero to 60 on the emotions speedway, and their intensity can’t be controlled. “At that point everybody in the family has to deal with it, and because people need to have emotions responded to, this only reinforces the person getting to emotional extremes,” Baugh said. Consequently, this becomes the only way the person knows how to manage emotional situations.In other words, a person with borderline personality disorder rarely makes a conscious decision to manipulate anyone. When a person isn’t having their needs met, they resort to extreme behaviors, according to Neil Bockian, Ph.D, founder and president of Behavioral Health Associates and co-author of New Hope For People with Borderline Personality Disorder. These behaviors then get reinforced when family members or people who don’t normally pay attention to them rush in, he said. When loved ones get burned out, the person with BPD starts escalating the behaviors.
- It’s untreatable. “The research shows convincingly that some treatments for BPD are remarkably effective,” said Kristalyn Salters-Pedneault, Ph.D, a clinical psychologist who specializes in BPD and writes a blog on About.com on the disorder.
- BPD is a life sentence. According to Alexander Chapman, Ph.D, president of the DBT Centre of Vancouver and co-author of The Borderline Personality Disorder Survival Guide: “In a recent study of patients with BPD who were hospitalized and then released, up to 70 percent no longer met criteria for the disorder at some point in a six-year follow-up period. Of those people who stopped meeting criteria for the disorder, 94 percent of them never met criteria again across the six years.”
- People with BPD aren’t trying hard enough. According to Joan Wheelis, M.D., director of the Two Brattle Center in Cambridge, Mass., “it isn’t that clients aren’t motivated, but that there is significant emotional, cognitive and behavioral dysregulation associated with the disorder.” People don’t realize just how considerable their deficits are. Many are very intelligent, talented and productive so it’s hard to believe, she said. “The person is doing the best they can given their current mental state,” Bockian said.
According to Salters-Pedneault, “BPD is best treated with a multi-method team approach,” which might include an individual and group therapist and a psychopharmacologist to manage medication. It’s this team who then “can determine the treatment of choice for an individual patient,” said S. Charles Schulz, M.D., head of the department of psychiatry at the University of Minnesota Medical School.
However, too many treatments can result in a “non-treatment treatment,” where the client isn’t fully engaged effectively in therapy, Dr. Wheelis said. She noted the importance of having “a primary clinician who’s responsible for the architecture of the whole treatment.”
Psychotherapy is the central treatment for borderline personality disorder. “To date, the gold-standard treatment for BPD is DBT (dialectical behavioral therapy),” Salters-Pedneault said. While there’s no way to say that DBT is superior — to date, no studies have compared all treatments in a “horse race” — judging by the quantity and quality of the studies that support DBT, it’s currently the best form of treatment, she said. Other promising psychosocial treatments include schema-focused, mentalization-based and transference-focused therapy.
Medications are sometimes prescribed to reduce symptoms of BPD or to treat a co-occurring disorder (such as bipolar disorder) and may help in conjunction with psychosocial treatments. According to Dr. Schulz, while studies haven’t been conclusive, some research has found that individuals who participated in DBT and took olanzapine (Zyprexa) experienced a reduction in symptoms when compared with individuals who attended treatment but took a placebo.
Dr. Wheelis, who advocates the use of medication, worries that “medication may be prescribed too frequently, leading to polypharmacy.” Additionally, “medication for symptoms of BPD can sometimes interfere in teaching the client that they can tolerate and cope with their emotions head-on,” she said.
Dialectical Behavior Therapy (DBT)
Developed by Marsha Linehan, Ph.D, DBT is based on cognitive-behavioral therapy and helps individuals with BPD manage their emotions, develop healthy relationships and lead a meaningful life. “DBT helps people to come to regulate their emotions and be able to truly enjoy life,” according to Baugh.
DBT consists of individual therapy, group skills training and phone coaching. Each week, individuals spend one hour with a therapist and two hours in a group session and complete assignments between sessions. Because symptoms affect every part of a person’s life, “one hour of therapy a week is just not going to cut it,” Salters-Pedneault said.
DBT requires at least a six-month to a year-long commitment, because it’s highly structured, and it takes six months to go through all the modules in a skills group once, Baugh said. It’s often more effective for clients to practice these stages a second time to cement skills and start chipping away at any trauma.
The first stage addresses suicide and self-harming behavior. Stage two involves treating emotional trauma from the past. Stages three and four help clients work on “problems of living and develop their capacity for joy and a sense of being comfortably at home in the universe,” Baugh said.
Challenges & Strengthening Recovery
To get the most benefit out of therapy, and common to DBT practice, Dr. Wheelis asks her clients to tape-record their sessions. “By listening to the session during the week a client can learn more about their struggles.” This can be especially useful for emotionally challenging sessions. Her clients are required to spend a minimum of 20 hours each week participating in meaningful activities outside of therapy (e.g., church, charity, work). The goal is to help individuals develop a life worth living.
Keep in mind that therapy is a process, so “it’s important to be patient, work hard and give therapy a chance to work,” Chapman said. Approach each new skill or lesson with an open mind. For instance, people may doubt the usefulness of mindfulness skills, but with practice and time, many say it’s “the most helpful skill they’ve learned.”
“Sometimes therapy can be like being on a long hike and staying the course despite thunderstorms, blizzards and so on,” Chapman said. If you find yourself losing motivation or wanting to skip sessions or homework, Chapman recommended asking your therapist for help. He helps his clients “come up with at least three critically, life-and-death-important reasons for sticking with therapy, and remind themselves of these reasons when things get rough.”
Ultimately, “Try your best to be kind, compassionate, nonjudgmental and understanding toward yourself… accept yourself for who you are right in this moment, and at the same time, find ways to help improve your life. Remember that you are not to blame for your problems, but you can do something about them,” he said.
Finding Treatment for Borderline Personality Disorder
“Treatment for BPD is available and it is effective, but it may take time and effort to find the right provider,” Salters-Pedneault said. Look for a provider who specializes in BPD. Behavioral Tech has a list of DBT specialists, and the non-profit organization TARA has more information. If there isn’t a specialist in your area, Chapman suggested checking your local college for psychologists or a psychological association, which may have referral directories.
You also can contact mental health professionals at a local hospital or medical center for a referral to programs or clinicians who specialize in BPD. Some areas have mental health directories. For instance, Vancouver has the “Red Book,” which lists mental health services in your community.