By John M. Grohol, Psy.D.
Borderline Personality Disorder is experienced in individuals in many different ways. Often, people with this disorder will find it more difficult to distinguish between 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-mutiliating behavior. These are sometimes very difficult items for a therapist to understand and work with.
Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings. Controversy surrounds overmedicating people with this disorder.
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. 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. It seeks to teach the client how to learn to better take control of their lives, their emotions, and themselves through self-knowledge, emotion regulation, and cognitive restructuring. 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.
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. Phillip W. Long, M.D. also notes that:
“The therapeutic alliance should form within the patient’s real experiences with the therapist and with the treatment. The therapist must be able to tolerate repeated episodes of primitive rage, distrust, and fear. Uncovering is to be avoided in favor of bolstering of ego defenses, in order to eventually allow the patient to be less anxious about potential fragmentation and loss. The goals of therapy should be in terms of life gains toward independent functioning, and not complete restructuring of the personality.”
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 ...
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