Some common sense about psychotherapy with 'Borderline Personality Disorder' (also known as Emotionally Unstable Personality Disorder)
Borderline Personality Disorder (the DSM term) and Emotionally Unstable Personality Disorder (the ICD-10 term) have become increasingly common diagnoses amongst psychiatrists in recent years. They refer to a broad constellation of characteristics, including: impulsiveness, rapidly shifting states of mood and emotion, intense conflictual feelings in interpersonal relationships, problems in regulating emotion, attempts to manage emotions by use of drugs, alcohol, or self-harm. In some cases (but not all), childhood trauma, abuse, or other adverse circumstances have been present in childhood.
Many people with the more complex problems seen in mental health or psychiatric services could be given such a diagnosis. Like some other psychiatric diagnoses, it is not particularly precise and has relatively flimsy scientific underpinning (Boyle 2007; Pilgrim 2001). Unlike more physical medical conditions, there is no objectively identifiable underlying disease process of which the descriptive signs are symptoms. It is simply that clinicians agree to call certain patterns of behaviour and mental states by these diagnostic terms. The underlying reasoning can be quite circular. Thus, one might ask: “Why does Sally behave impulsively, have volatile moods, unstable relationships, and sometimes cuts herself?” – and the answer might be “Because she has a Borderline Personality Disorder”. However, if we then were to ask: “How do we know that Sally has a Borderline Personality Disorder?, the answer would be “Because she has volatile moods, unstable relationships, and sometimes cuts herself”. The diagnosis of BPD can have the appearance of explaining something, but in fact explains nothing.
Sometimes people like to have a label for their problems – it can give a sense of order, perhaps reassurance, and a feeling of belonging to a group of other people with similar problems. On the other hand, a psychiatric label can have a variety of negative connotations and implications – particularly if the person then identifies with that label (Shaw & Proctor 2005). Thus, Coles (2011) comments "The diagnosis of borderline personality disorder is stigmatising, and whilst claiming scientific credibility and being imposed on people in the name of expertise, lacks basic scientific worth." [p 17]
The term ‘Borderline Personality Disorder’ can be inherently misleading, particularly to those not in the psychiatric professions, or to those who have not studied the evolution of psychiatric diagnoses. The word ‘borderline’ suggests something ‘mild’, perhaps ‘on the border’ of a condition – as if indicating ‘not quite a personality disorder’. In reality, it denotes quite a severe form of personality disorder. The roots of the term are in earlier psychoanalytic discussions of conditions that are at the borderline of ‘neurosis’ and ‘psychosis’, and in the early concept of ‘borderline schizophrenia’. In practice, people are given this diagnosis along a wide spectrum of levels of functioning – from people who can scarcely function in the world without extensive support, to those who hold down demanding jobs and have relatively stable marriages or partnerships.
A person may be given a diagnosis of Borderline Personality Disorder and still have other psychiatric diagnoses, such as depression, bipolar disorder, anxiety conditions, ADHD, a sexual disorder, autistic spectrum problems, or indeed another personality disorder. This ‘comorbidity’ is part of the problem with psychiatric diagnoses. Many of them can overlap with each other, suggesting they are not really discrete and separate conditions. One consequence is that BPD can mean many different things (O'Donoghue 2007).
Despite the unreliability and questionable validity of many (although not all) psychiatric diagnoses, there is currently a politico-economic pressure towards giving people specific diagnoses and then providing recommended psychiatric and psychotherapeutic treatment based on those diagnoses. As a result, there are various forms of psychotherapy that have become recognised as valid treatment for BPD. In order to be recognised in this way, the developers of the method must undertake research trials that show the method to be helpful for people with the designated condition. Once this is done, the method becomes a ‘brand’ (often trademarked) which is marketable, just as a drug is. Money is made by selling training and supervision in the approach, and those trained in the method can also sell their expertise in the psychotherapeutic market place.
Why is this a problem? It is because there is an inherent dishonesty in the system. By and large, the following statements are true, based on decades of research: [1] Whenever genuine psychotherapies are compared they are found to be more or less equally (but modestly) effective; [2] there is more variation in effectiveness amongst psychotherapists than between psychotherapies (Wampold 2001). The second problem is that psychotherapies have much in common, and the claims of difference and distinctiveness are often spurious. For example, there are several contemporary therapies, recommended for BPD and other personality disorders, that are essentially derivatives of psychoanalysis, albeit with some particular aspect being given more emphasis. Whilst these may be found to be somewhat effective, there is no data to indicate that they are actually more effective than other variants of applications of psychoanalysis. In order to avoid causing offence to colleagues, I will not discuss these methods specifically by name.
For any clinician familiar with the kind of problems that get called BPD, it is not difficult to appreciate what is needed for an adequate psychotherapeutic and psychiatric approach. These are:
1. Clarification of the general pattern of the constellation of emotional, behavioural, and relational problems the person is experiencing – and its history.
2. Helping the client become aware of, and understand, the emotions and anxieties and not-fully-conscious thoughts that are driving him or her – and the defensive strategies the client uses to avoid these.
3. Helping the client become able to tolerate and manage their emotions without resorting to drugs, alcohol, bulimia or anorexia, or self-harm.
4. Processing traumatic interpersonal experiences (particularly from childhood) that have left traumatic stress imprints within personality.
The more effective approaches and therapists tend to do these. Some will work in a more exploratory way, working through the issues primarily as they become apparent in the therapeutic relationship (psychoanalytically based approaches), whilst others will adopt a more teaching or coaching style (cognitive-behavioural approaches). There is, of course, no need to stick to a pure approach. It is rational and constructive to combine intelligently the helpful elements of a range of methods. Where some therapeutic endeavours may be less successful is in failing to process traumatic experience, which the client may also prefer to avoid.
Adjunctive approaches, such as the methods of energy psychology, address only tasks 3 and 4 in the above list. Tasks 1 and 2 must still be done, and these require traditional or conventional psychotherapeutic skills – and a depth of understanding that not all practitioners have.
There are some limiting factors that seem, in my experience, to act as a brake on therapeutic progress. One of these is the client’s neurobiologically-based temperament – the bedrock that is not ‘caused’ by psychodynamics, negative cognitions, core schemas, interpersonal traumas, or by anything ‘psychological’. For example, some people with BDP have ADHD traits, such as an intolerance of frustration, mood volatility, low threshold for boredom, sensation-seeking, a deficit in forward planning, proneness to rage, etc. – factors that are not easily modified. Possibly these can be alleviated with relevant medications.
Another limiting factor is the capacity of the therapist to cope with the intense emotions generated in the therapeutic encounter with a person with BPD. This concerns not only the training and experience of the therapist, but also his or her natural personality. Regarding the former, there is great variation in training of therapists. Clinical psychologists, for example, may never have undergone any therapy of their own, and their clinical training to doctorate level (in the UK) is only three years (following a first degree). Psychoanalysts, by contrast, are likely to have already trained as psychiatrists or psychologists (although not always) and then (usually in mid-life) undertake a very demanding programme that includes 5 x per week personal psychoanalysis over many years, as well as a similar intensity of work with clients. The purpose of this is to provide the analyst with thorough understanding of the deeper parts of the mind, both their own and that of others. However, even with extensive training and personal analysis, there are limits on the work the individual practitioner is able to tolerate or be skilled in. Different styles and different patients suit different practitioners. Some client-therapist matches are better than others.
Even though there have been some modest advances in our understanding of the nature and origin of the patterns of problems that tend to be called BPD (or Emotionally Unstable Personality Disorder), and in our capacity to offer relevant help, the position is still far from satisfactory. We must continue to look for deeper understanding and better methods of helping. These are likely to involve the use of methods to assist people in changing the neurobiological imprints of early adverse circumstances.
References:
Boyle, M. 2007. The problem with diagnosis. The Psychologist 20 (5) 290-292
Coles, S. 2011. Borderline Personality Disorder: This House Believes. Clinical Psychology Forum 225 September 15-18
O'Donoghue, W. T., Fowler, K. A., & Lilienfeld, S. 2007. Personality Disorders: Towards DSM-V. Sage. London.
Pilgrim, D. 2001. Disordered personalities and disordered concepts. Journal of Mental Health. 10. 253-265
Shaw, C. & Proctor, G. 2005. Women at the margins: A critique of borderline personality disorder. Feminism and Psychology 15 483-490
Wampold, B.E. 2001. The Great Psychotherapy Debate. Routledge. London