Therapy Guide: Borderline Personality

In almost a decade and half of practicing as a psychotherapist, the one diagnostic label that almost always elicits immediate and severe rejection in conversations is that of Borderline Personality Disorder (BPD). Something about the very name makes people visibly uncomfortable. That in itself isn’t unusual in therapeutic discussions because of the stigma and associated conditioning about mental health and illness. However, when it comes to BPD, there is often a visceral vetoing. There is a palpable fear that so much as accepting the diagnosis or putting a name to the condition might make them feel more isolated and confirm their worst fears.

BPD has been unfairly cornered in both psychiatric and popular dialogues because of a host of reasons. Pop cultural tropes often depict people with BPD as some sort of unhinged, dysregulated and intentionally disruptive people. Caricaturish portrayals condescend to reducing a complex and often misunderstood condition as merely a questionable form of “crazy”. Literature, film and TV characters with BPD are written as difficult-to-deal with people who make life difficult for others around them. This is a hostile stereotype that furthers the alienation experienced by folks who live with a borderline personality.

For a long time even within the healthcare community, BPD was poorly comprehended and by extension, poorly treated. Psychiatrists, medical practitioners and even psychotherapists perceived it as too trying with an uncertain recovery path. A lot of the time these views were based on failure of intervention methods that were just not suited for people living with BPD. Thankfully, we are seeing changes thanks to better research, specialized therapies and more informed outreach along with community support rooted in a rights based approach to mental wellbeing.

Originally “borderline personality disorder” was called ““borderline personality organization” to reflect how a personality organized itself around borderline tendencies in terms of cognitive, emotional and behavioural displays in an individual. Diagnostic language in psychiatry/psychology is of some significance in how it can help healing or how it can direct imputation. It was a classification criteria for clients/patients who were neither “psychotic”(externalized) nor “neurotic”(internalized) but somewhere in between, hence : borderline.

The taxonomy shifted from "organization" to "disorder" due to various reasons but largely on account of excessive promotion of scripting (medication), drugs placement and pushing in an array of psychopharmacological “cures” that were perhaps more focused on merely selling medicines at one point. Very rarely are clients/patients/service users explained the etiology of the condition. The greater challenge in BPD is both emotional regulation & processing of emotions. This is on a different tangent to, say, clinical depression where emotion processing in itself is the root of depressive/dissociative cycles at times. There is also a pervasive socio-cultural component to BPD and we must be aware of how deep-rooted discrimination and poor treatment of certain communities on account of race, gender, class, caste, sexual orientation, among other identity-based differentiation is equally relevant for consideration when looking at borderline personality.

A personality “disorder” is as much a function of innate or instinctive behaviours as it is a product of environmental reinforcement/punishment schedules.

What is Borderline Personality Disorder ?

BPD is classified as one of the 10 personality disorders that fall under Axis II of the Diagnostic Statistic Manual-V which is used by quite a few clinical psychologists for diagnostic purposes and case formulation. It is marked by sudden shifts in emotive states, moods and behaviours that frequently cause unexpected episodes of impulsivity, heightened irregularity in emotional states along with a prolonged impairment in the ability to establish and sustain healthy relationships. BPD patients/clients can also report episodes of depression, anxiety, irritability and even depersonalization and dissociation — separately or co-morbid — where each may last for a matter of hours to days and even weeks.

People with a borderline personality might experience average to severe distortions along the lines of self-worth and relationships. Moods can become unstable and fluctuate easily accompanied by disproportionate responses to certain perceived stressors. There could also be heightened emotional reactivity and feelings of emptiness accompanied by fears of rejections.

Based on conversations with my therapy clients who live with BPD, I can list four common triggers:

1. Criticism - Any form of feedback, particularly critical feedback is considered a direct hit against the sense of self. This worsens if the feedback is actually negative criticism. Being criticized sets off a process in which a person starts to only see what's wrong with them or what others think is wrong with them. It can also lead to splitting - a black and white view of self, others and the world at large. A lot of times it originates during childhood where either the individual was not offered healthy validation along with constructive criticism or was unattended to at important junctures where they needed help and assistance, not reprimand.

• Rejection: A friend of mine who lives with BPD says he walks into every relationship assuming that he will be rejected sooner than later. While this could be an existential fear for a lot of us, in BPD people often act out on the belief that this is likely to be true. The intimidation of rejection by others can lead to disconnection and undervaluing of self and dent self-respect. A form of circular pattern might emerge where either one pleads with others not to be rejected or ends up rejecting others constantly. Either way, the behavioural response might lead to feelings of intense hurt.

• Abandonment - There is a pervasive fear of being left behind. Someone once mentioned how they thought they were “easy to discard”. This can become a barrier in relationships when the other party is busy or unable to attend to someone’s needs constantly. On the flip side, they might also not leave relationships which are no longer working because they fear that any kind of separation will lead to the worst kind of loneliness. The looming shadow of abandonment can cause unnecessary doubts escalating in fights and, at times, bridge-burning dissonance.

• Isolation: One of the reasons the fear of abandonment can become so omnipresent is the accompanied possibility of isolation. Being by oneself has somehow become a very undesirable proposition. Either due to being left alone as a child or not having support when you needed it at critical points in your life, isolation is the image of a neverending prison without reprieve. The impending pain of being forgotten in a dust storm of other experiences turns up a lot in therapy sessions.

While we talk a lot about the challenges associated with BPD, what should also be noted is that individuals who live with BPD may not be intentionally trying to damage their relationships. My therapy clients who have been diagnosed with it are often enthusiastic, humorous, joyful, and quite perceptive people who also value the people in their lives quite a bit. They do experience remorse and regret when something goes awry in their interactions. They don’t give up on the people that matter to them even when they struggle to maintain a consistent relationship with them. They try hard to make sense of their situation and even find ways to channel it into creative outputs so they can express themselves in better, more ordered ways. Because BPD brings out a level of emotional hyper-sensitivity, they are also able to recognize the pains and aches of others around them even when they are not being directly expressed.

A lot of those in therapy are aware of their inconsistent behaviours. A lot of them are tired of having to explain that it isn’t all intentional or planned or, worse, “manipulative”. The last being akin to a slur for them.

A lot of people who live with BPD are also living with a type of invisible trauma. Research points out the correlation between childhood trauma and experiences of BPD. These factors, in combination, help shed light on the predicament of anyone who lives with BPD and is uncritically judged because of stigma attached to a diagnostic label.

Here is short guide that sheds light on some prevalent and useful forms of therapies available to folks who are battling BPD and are considering getting help -

1. Dialectical Behavioural Therapy: DBT was developed by American psychologist Marsha Linehan who herself has survived an exacting battle with mental illness. It traces its origins to Cognitive Behavioural Therapy but has been modified from the original CBT model to concentrate on the impulses and emotional requirements of people who experience emotions in a far more unsteady yet all consuming way. DBT is the most widely practiced form of therapty for Borderline Personality Disorder and has shown particularly good results when it comes to tackling self-harming tendencies, suicidal ideation, impulsivity binges & relationship dysfunctions. In a nutshell, the “dialectical” part of DBT branches into striking a balance between two seemingly disparate positions— Acceptance & Change. In a lot of cases, people with Borderline Personality might experience repeated negation from self and others about their emotional issues. In DBT, the focus is two fold— allowing a client to experience acceptance from the therapist and themselves while also figuring out ways to improve and change the harmful patterns of thinking and behaving that lead to dissonance and damage.

2. Systems training for emotional predictability and problem-solving (STEPPS)

STEPPS is a value-added therapeutic intervention that helps reduce excessive dependency on therapy which can be an unwanted outcome of BPD specific treatments. It follows a 20 weeks, manual-based group therapy plan and has been inculcated from an evidence based therapeutic approach. Evidence based therapy combines applied clinical expertise with tested empirical research that has satisfied scientific criteria. STEPPS is modelled on a psycho-educational format and therefore is largely oriented towards teaching clients resonant ways to handle their distress through coping mechanisms. It again bases itself largely on the CBT framework and strives to create a shared language in the group. There is an emphasis on managing the condition and shifting position from blame to awareness. It is not as effective in handling suicidal ideation as DBT but on account of its value-added angle, it has shown repeated success in reducing depressive symptoms and helping clients find ways to relax during agitated phases.

3. Mentalization-based therapy (MBT): MBT is an integrative form of therapy that draws its influences from Cognitive Behavioural models, humanistic and existential psychology, psychodynamic approaches as well as socio-ecological aspects of understanding mental health. Mentalization refers to an individual’s ability to understand mental states pertaining to themselves as well as those with whom they engage or interact. The ability to successfully participate in mentalization allows us access to perception, imagination and recognition of human (& other) mental states in context to ideas, desires, wants, needs, beliefs, values, A common feature of BPD tends to be lack in affect regulation— an inability to voluntarily manage your affect or mood. There are waxing and waning cycles of understanding the nature and direction of emotional responses in a more consistently healthy way. Sudden emotional outbursts without an immediately traceable trigger tend to populate the BPD spectrum. MBT helps create specific mental awareness for clients where they have space to comprehend how they feel in addition to how others feel and how they can respond to those feelings. This form of therapy benefits clients in reducing conflicts within their intimate relationships.

4. Transference focused psychotherapy (TFP): TFP is built on Otto F. Kernberg’s object relations model of borderline personality disorder. It centers itself on a psychodymanic approach and has a very clearly defined, highly meticulous and structure-bound treatment path. This form of therapy is aimed at gaining insight and analyzing what internalized representations and structures a BPD client might hold about their own self as well as others in their environment. It tries to harmonize the “broken off” facets to self and others and tries to focus its lens on the distortions in a client’s perception of themselves and others.TFP is keenly directed towards harm reduction and detouring clients from suicidality while facilitating improved behavioural control and developing the abilities needed for emotional regulation that help meaningful relationships.

These are some of the more widely accepted therapies that have proven to be useful for patients and clients who experience Borderline Personality Disorder. Apart from these specific therapeutic options, Minfulness Based Therapies that include meditative and self-compassion streams of cognitive, behavioural and emotional pattern restructuring, including Jon Kabat Zinn’s Mindfulness Based Stress Reduction, have shown to work well with clients in alliance to the earlier mentioned therapeutic models. Apart form these, somatic/bodywork styled interventions as well as art immersions and creative expression can also contribute towards wellness. It is important to remember that taking care of physical health can show marked improvement in managing emotional homeostasis and vice versa. Spending time in nature, listening to soothing music, activities such as swimming, dancing or cycling, guided meditation, journaling, spending time nourishing your mind and body can all work towards creating holistic and longterm wellness.

When I think of feelings and being flooded by them, I remember that Leslie Jamison wrote in “The Empathy Exams: Essays” ―

“Feeling something was never simply a state of submission but always, also, a process of construction.”