working with borderline personality disorder

We have all had them; whether in a community mental health, hospital, or private practice setting. Patients who have some tacit quirk that seems to reach under our professional façade and frustrate us.

Sometimes, we can figure out what the trait is and at other times we can’t quite put a finger on what it is that is creating the obstacle to joining. At other times, we may begin heading down the road of diagnosis of Borderline Personality Disorder.

These patients represent one of the most difficult diagnosis in which to treat. As frustrating as this disorder may be for therapists it is perhaps one of the most debilitating for the patient and their family alike. Often these patients are desperate for help and yet, as desperate as they are, they struggle for a means to tread water in a world that they cannot understand or thrive in.

Treating Borderline Personality Disorder

The following are some highlights for treatment of Borderline Personality Disorder.

Borderline Personality Disorders Tend To Bleed Together With Other Disorders

When treating a patient with BPD it is important to assess and treat other potential mental health disorders that often accompany these patients.

The diagnosis that are comorbid with this disorder tend to be Major Depression, Dysthymia, Substance Abuse and a concurrent disorder such as Narcissistic or Antisocial Personality Disorder. Therefore, any patient that seems to present with this possible disorder would strongly benefit from a comprehensive psychiatric evaluation.

Underlying Assumptions of BPD Patients

BPD patients tend to personify the concept of cognitive distortions in the area of “Black and White” thinking. They classify themselves and others as “good or bad” and  can’t classify people in the areas of “shades of gray.” Those that are on the positive side should be rewarded while those on the negative side need be ostracized or punished. This “Black and White Thinking” must be addressed.

A word of caution, if a BPD patient comes to you and states that you are the “best” therapist remember that they can swing to the very other side of the pendulum quickly and unpredictably.

Look Towards Previous History to Find Current Reasons for Diagnosis

Abuse, especially sexual (it accounts for as much as 70% of patient history), as a child seems to be a key trigger for development of this personality disorder. Parental separation or disengagement is also a co-occurring factor with these patients.

There Are a Host of Misconceptions in the Therapy Arena About BPD

Many believe that BPD is a “female” disorder while, in fact, it is more common in women it still occurs in men. Another myth is that BPD is ineffective to counseling. While it is true that BPD is resistant to many counseling paradigms; certain counseling models are more effective in working with these patients.

they classify themselves and others as good or bad

Responsibility is a Key

Patients must begin to accept responsibility in all facets in their treatment. Though this is a common mantra for all recipients of counseling. This, however, is the key to successful counseling for patients with BPD. If they have substance abuse issues this precludes effective counseling for other issues and therefore they must seek substance abuse treatment.

In all of their relationships they must seek to recognize their responsibility in development of maladaptive relational patterns. Responsibility in relationships must also be confronted directly as opposed to using maladaptive patterns of fleeing, blaming, going on the defense or using substances to dull the pain of relational issues.

Seek to Look Under the Anger for the Larger Roots

Patients who have BPD tend to recognize an overwhelming anger that comes in waves and often leads to impulsive waves of anger that jeopardize even the closest relationships. While patients may state they are in need of anger management; the truth is they must see a spectrum of emotions that are at the roots of this anger.

Frustration, fear, anxiety, depression, jealousy are all at the roots of this anger. Therapists, therefore, are better off seeking to address these underlying emotions and making patient aware of these emotions in relational matters.

Cognitive Distortions and CBT are Important Elements

Common cognitive distortions issues of “black and white thinking, generalization, blaming” and the host of other distortions that are listed under distortions must be addressed in the sessions. Providing journaling through paper or in smartphone applications will help patients be aware when they are using cognitive distortional thinking and placing themselves on a healthy mental track when they are out of session.

Dialectical Behavioral Therapy (DBT) is Determined to be An Effective Modality for BPD

DBT recognizes that certain people tend to have particular sensitivities to and reactivity to situations that may present emotionally challenging circumstances. That being said, these people also tend to have an extremely difficult time in self-soothing and returning to a baseline level of emotional stability. Conversely, they also lack the coping skills for seeking a means of returning to a base level of emotional calm and need to be taught these strategies.

Developing an Outline for DBT Sessions

DBT sessions ideally consist of weekly individual meetings with the therapist. On this order, a review of the past week’s issues that have occurred are addressed. A look into deeper issues that may have created the conditions for BPD.

PTSD and self-esteem issues that crop up from these discussions must be handled accordingly. Finally, suicidal ideation must always be assessed on a session to session basis. BPD patients can tend to be highly emotionally reactive and impulsive which creates an ideal environment for suicidal ideation. Therefore, a safety plan should also be discussed and, as necessary, have family members involved in this portion of the counseling.

Consider Counseling Therapy with a DBT Paradigm

BPD patients tend to view their relationships in comparison to others. With this in mind, group counseling with a DBT paradigm can be an excellent modality to working with these patients. This is especially effective in addressing and role-modeling relational issues.

Being “Mindful”

BPD Patients are very quick to judge situations immediately and harshly Teaching them in session to look at a situation without any judgment but instead observing, learning and participating is key. Along with “staying present,” learning “self-sooth” and decrease stressors.

Taking Care of One’s Self

Due to a chronic lack of awareness of self and others, BPD Patients often do not know how to do self-care. Encouraging them to eat right, sleep right, avoid substance usage are important life skills that can go a long way to avoid aggravation of BPD symptomology.

Why It Is Not Bipolar Disorder

Often BPD and Bipolar Disorder are confused as differential diagnosis. There are important distinctions, however, Bipolar Disorders will often cycle without any apparent social trigger. BPD patients tend to have mood cycles in reaction to an event often relational or perceived abandonment issues. BPD patients will often discuss these triggers in terms of “love-hate” relationships where Bipolar Disorder patients will not have a noted social trigger.

Living with someone who is diagnosed with BPD can be very difficult

Suicidality Assessment As Often As Possible Is Key

As mentioned before BPD patients tend to be impulsive and reactive. They have been demonstrated to have a greater level of suicide ideation and attempts more than any other diagnosis.

When they are in pain they often describe wanting to find any and all means to escape this feeling (including unfortunately suicide). In knowing this, it is important to develop any immediate safety plan (even if there is no active suicidal threat). This may mean getting other family members involved to recognize psychiatric emergencies and know when and where to utilize resources accordingly.

Family Counseling

Living with someone who is diagnosed with BPD can be very difficult. They can be very close and loving one moments and demonstrated hatred and distancing the next. Family therapy therefore will not only help the family but will also help the patient as they will have support when they need it most and are most irritable and vulnerable. Again, they can also help find resources of a patient is having a psychiatric emergency.

Marital Counseling

Concurrent marital counseling may be suggested or needed as communication skills are BPD patients weakness. Learning “I” Messages, seeking realistic versus grandiose opinions of spouse as well as teamwork versus power struggles are all elements for marital counseling.

BPD Pain

Often times, when a BPD patient comes in the doors of a therapy office they can be described as being “a pain.” They can be described as difficult, irritable, and demanding to therapist, receptionist’s and other’s that they come in contact with.

This pain, however, is nothing compared to the pain that a BPD patient feels on a daily basis. These people are deathly afraid of abandonment and will grab whoever they can to avoid drowning in their own fears.

Unfortunately, they often fulfill the prophesies that they so fear and thus create even more anxiety. BPD patients often describe the pain of relationships of that as a fresh and raw sunburn that is aggravated with each perceived social slight that they inevitably feel on a daily basis.

The Therapist

As therapists, we may be the only one who can apply a therapeutic salve to ease that pain. We can see beyond anger, irritability, and criticism to a vulnerable and hurting human being who is in desperate need of help but cannot find a means of getting a handle on the quicksand that is their constant thoughts of abandonment.