Borderline personality disorder is experienced in individuals in many different ways. Often, people with this disorder will find it more difficult to distinguish reality from their own misperceptions of the world and their surrounding environment. While this may seem like a type of delusion disorder to some, it is actually related to their emotions overwhelming regular cognitive functioning.
People with this disorder often see others in “black-and-white” terms. Depending upon the circumstances and situation, for instance, a therapist can be seen as being very helpful and caring toward the client. But if some sort of difficulty arises in the therapy, or in the patient’s life, the person might then begin characterizing the therapist as “bad” and not caring about the client at all. Clinicians should always be aware of this “all-or-nothing” lability most often found in individuals with this disorder and be careful not to validate it.
Therapists and doctors should learn to be like a rock when dealing with a person who has this disorder. That is, the doctor should offer his or her stability to contrast the client’s lability of emotion and thinking. Many professionals are turned off by working with people with this disorder, because it draws on many negative feelings from the clinician. These occur because of the client’s constant demands on a clinician, the constant suicidal gestures, thoughts, and behaviors, and the possibility of self-mutilating behavior. These are sometimes very difficult items for a therapist to understand and work with.
Like with all personality disorders, psychotherapy is the treatment of choice in helping people overcome this problem. While medications can usually help some symptoms of the disorder, they cannot help the patient learn new coping skills, emotion regulation, or any of the other important changes in a person’s life.
An initially-important aspect of psychotherapy is usually contracting with the person to ensure that they do not commit suicide. Suicidality should be carefully assessed and monitored throughout the entire course of treatment. If suicidal feelings are severe, medication and hospitalization should be seriously considered.
The most successful and effective psychotherapeutic approach to date has been Marsha Linehan’s dialectical behavior therapy (DBT). This treatment was originally developed to help chronically suicidal individuals. DBT combines crisis intervention support with other intervention practices that are theoretically grounded in Eastern meditative and acceptance-based philosophies. Research conducted on this treatment have shown it to be more effective than most other psychotherapeutic and medical approaches to helping a person to better cope with this disorder. DBT focuses on helping the client build skills in acceptance and tolerance of intense negative emotions as a means to take better control of their lives, their emotions, and themselves. In DBT, the therapist and client are expected to build a relationship where the therapist can help the client start to bridge the gap between “emotional” and “rational” interpretations of their world. In addition, client and therapist exchanges help the client negotiate a balance between acceptance and change of certain client tendencies (hence the term “dialectical”). The client must give the therapist permission to question/identify (in a moderately non-confrontational manner) distorted interpretations or inappropriate reactions the client may display over the course of therapy that are based on emotional reactivity rather than rational processing. Treatment targets are agreed upon, with self-harm taking priority. It is a comprehensive approach that is most often conducted within a group setting. Because the skill set learned is new and complex, it is not an appropriate therapy for those who may have difficulty learning new concepts.
Specifically, in DBT there are therapy modules that include exercises for improving self-knowledge, emotion regulation, distress tolerance, and cognitive restructuring. As a snapshot of DBT therapy, clients first learn to know and accept their “selves” (e.g., “I am a strong feeler”; “I have a fear of being abandoned”), while taking responsibility for and acknowledging certain destructive tendencies they have used to regulate their strong emotions (e.g., “I threaten people I love”; “I get into relationships fast so I won’t feel lonely”; “I cut and burn myself”). They learn that they are not necessarily bad or flawed individuals, but that their urges and actions typically serve as short-term strategies to relieve high distress tendencies, while preserving their distress in the long run.
By learning new coping skills they can improve their self-efficacy for handling situations more appropriately when strong negative emotions arise. For example, one exercise involves holding an ice cube in one’s hand when an individual has an emotionally reactive urge, such as to harm themselves.