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.
By building in a pause between the intense emotion and destructive reaction, as well as by diverting attention away from the emotion and onto the alternative sensation experienced (i.e., cold sensation on hand), by the time the ice cube melts, the patient may be in a better position now that the intensity of the emotion has reduced somewhat, to make a more rational behavioral decision. Additionally, the patient is able to have evidence that strong emotions do not stay in their heightened peak state forever; in fact, all emotions rise and pass naturally, and may not require any behavior besides waiting for their elimination.
Patients similarly learn to ride the waves of their distress in meditation and yoga using their breath as a navigation tool. Overall, the goal of the therapist is to establish realistic expectations in the patient (i.e., there is no “cure” for having intense negative emotions), to promote emotional acceptance and non-reactivity, and to instill skills to help the patient establish healthy ways of coping.
Like all personality disorders, borderline personality disorder is intrinsically difficult to treat. Personality disorders, by definition, are long-standing ways of coping with the world, social and personal relationships, handling stress and emotions, etc. that often do not work, especially when a person is under increased stress or performance demands in their lives. Treatment, therefore, is also likely to be somewhat lengthy in duration, typically lasting at least a year for most.
Other psychological treatments which have been used, to lesser effectiveness, to treat this disorder include those which focus on social learning theory and conflict resolution. These types of solution-focused therapies, though, often neglect the core problem of people who suffer from this disorder — difficulty in expressing appropriate emotions (and emotional attachments) to significant people in their lives due to faulty cognitions.
Providing a structured therapeutic setting is important no matter which therapy type is undertaken. Because people with this disorder often try and “test the limits” of the therapist or professional when in treatment, proper and well-defined boundaries of your relationship with the client need to be carefully explained at the onset of therapy. Clinicians need to be especially aware of their own feelings toward the patient, when the client may display behavior which is deemed “inappropriate.” Individuals with borderline personality disorder are often unfairly discriminated against within the broad range of mental health professionals because they are seen as “trouble-makers.” While they may indeed need more care than many other patients, their behavior is caused by their disorder.
Hospitalization is often a concern with people who suffer from borderline personality disorder because they so often visit hospital emergency rooms and are sometimes seen on inpatient units because of severe depression.
People with this disorder often present in crisis at their local community mental health center, to their therapist, or at the hospital emergency room. While an emergency room is an immediate source of crisis intervention for the patient, it is a costly treatment and regular visits to the E.R. should be discouraged. Instead, patients should be encouraged to find additional social support within their community (including self-help support groups), contact a crisis hotline, or contact their therapist or treating physician directly. Emergency room personnel should be careful not to treat the person with borderline personality disorder in blind conjunction with another set of therapists or doctors who are treating the patient for the same problem at another facility. Every attempt should be made to contact the client’s attending physician or primary therapist as soon as possible, even before the administration of medication which may be contraindicated by the primary treatment provider. Crisis management of the immediate problem is usually the key component to effective treatment of this disorder when it presents in a hospital emergency room, with discharge to the patient’s usual care provider.
Inpatient treatment often takes the form of medication in conjunction with psychotherapy sessions in groups or individually. This is an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning. It is, however, relatively rare to be hospitalized in the U.S. for this disorder. Long-term care of the person suffering from borderline personality disorder within a hospital setting is nearly never appropriate. The typical inpatient stay for someone with borderline personality disorder in the U.S. is about 3 to 4 weeks, depending upon the person’s insurance. Since this treatment is so expensive, it is getting more difficult to obtain. Results of such treatment are also mixed. While it is an excellent way of helping stabilize the client, it is usually too short a time to attain significant changes within the individual’s personality makeup.
Good inpatient care facilities for this disorder should be highly structured environments which seek to expand the individual’s independence.
Partial hospitalization or a day treatment program is often all that’s needed for people who suffer from borderline personality disorder. This allows the individual to gain support and structure from a safe environment for a short time, or during the day, and returning home in the evening. In times of increased stress or difficulty coping with specific situations, this type of treatment is more appropriate and more healthy for most people than full inpatient hospitalization.
Phillip W. Long, M.D. has noted:
“During brief reactive psychoses, low doses of antipsychotic drugs may be useful, but they are usually not essential adjuncts to the treatment regimen, since such episodes are most often self-limiting and of short duration.
It is, however, clear that low doses of high-potency neuroleptics (e.g., haloperidol) may be helpful for disorganized thinking and some psychotic symptoms. Depression in some cases is amenable to neuroleptics. Neuroleptics are particularly recommended for the psychotic symptoms mentioned above, and for patients who show anger which must be controlled. Dosages should generally be low and the medication should never be given without adequate psychosocial intervention.”
Antidepressant and antianxiety agents may be appropriate during particular times in the patient’s treatment, as appropriate. For example, if a client presents with severe suicidal ideation and intent, the clinician may want to seriously consider the prescription of an appropriate antidepressant medication to help combat the ideation. Medication of this type should be avoided for long-term use, though, since most anxiety and depression is directly related to short-term, situational factors that will quickly come and go in the individual’s life.
Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Encouraging the individual with borderline personality disorder to gain additional social support, however, is an important aspect of treatment. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.
Patients can be encouraged to try out new coping skills and emotion regulation with people they meet within support groups. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.
- Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., et al. (2006). Two-Year randomized controlled trial and follow-up of Dialectical Behavior Therapy vs. therapy by experts for suicidal behaviors and Borderline Personality Disorder. Archives of General Psychiatry, 63, 757-766.
- Verheul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). A 12-month randomized clinical trial of Dialectical Behavior Therapy for women with borderline personality disorder in the Netherlands. British Journal of Psychiatry, 182, 135-140.
- Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I., Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32, 371-390.
- Linehan, M.M. (2006). Treating borderline personality disorder: The dialectical approach. Guilford press.
- Linehan, M.M. (1993). Skills training manual for treating borderline personality disorder. Guilford press.