Borderline Personality Disorder

Revised and with a new afterword by the author

by John M Rathbun M.D.

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 [post traumatic stress disorder] 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 Personality Disorders.

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:

1) 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. 

2) 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. 

3) 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 

4) 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: 

1) Diagnosis in psychiatry is not a game for well-meaning amateurs. 

2) The best defense against illness is to carefully choose one’s parents. Practical application of this insight awaits further development. 

3) 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. 

4) 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. 

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