It
is vitally important that the patient get a good psychiatric evaluation
by a board-certified psychiatrist
who specializes in personality disorders before treatment begins. It
is worthwhile to do this because the course of the patient's entire treatment
may be determined by an initial evaluation. Local chapters of mental health
organizations (i.e. the American Psychiatric Association) can help patients
and families find such a practitioner in the patient's general geographic
area.
By
the time a family member has been diagnosed as suffering from a
borderline personality disorder, so much stress has been generated
in the family that
everyone is affected. For this reason, it is advisable for the entire
family to seek support services.
If outpatient therapy reaches a stalemate or is interrupted by repetitive
suicide attempts, or if the patient cannot stay consistently with
a therapy and continues to disrupt his or her own life and that
of others, the
family and patient may want to seek consultation in a center specializing
in the
treatment of borderline personality disorder. A thorough assessment
may lead to the recommendation of a more specific individual therapy,
adjunctive
group
or family therapy, referral to substance abuse treatment, or more
intensive treatment in the form of hospitalization or a day hospital
program.
Day
hospital treatment, where the patient is committed to attending daily
therapy sessions and workshops but resides at home, is helpful
both in
enabling patients to understand their problems and how these affect
others, and also
in bringing patients into close daily contact with others who are
working on those problems. Borderline patients tend to support
each other–sometimes
in a negative way, to be sure, but more often in a very positive
way. Articulate, candid and forthright, they are often extremely
effective in
cutting through
the denials and excuses and the blaming of others that so hamper
a person's ability to see his or her own problems. The recognition
of the illness
and the determination to overcome it have everything to do with
successful treatment.
Without adequate treatment, the illness is lifelong, and all too
often ends in suicide. With good treatment, the outlook is very
favorable indeed
in many cases. Among the 500 borderline patients studied by Dr.
Michael Stone at the Columbia Psychiatric Institute over more
than 20 years, 4 out of 10
are clinically recovered 10-20 years after their point of entry
into the study during hospitalization. Seventy-five percent are
self-supporting and doing
reasonably well. The suicide rate was 7% as of 16 years post-admission.
The patients who recovered tended to be those who persisted in
psychotherapy
over
many years.
Treatments for BPD have improved in recent years. Group and individual
psychotherapy are at least partially effective for many
patients. The individual outpatient psychotherapy for the borderline
patient usually consists
of 2-3
therapy sessions a week over a period of years. The therapist
works with the patient to understand the meanings and motives
of his
or her behavior,
and
to strengthen his or her capacity to endure frustration,
anger
and loneliness without acting impulsively upon those feelings.
One form of therapy that is psychodynamic in nature, is
known professionally as transference-focused psychotherapy (TFP). This
therapy is geared primarily at understanding the underlying
causes of the
patient's
borderline condition and working to build newer, healthier
ways of thinking and behaving for
the patient.
About
Transference-Focused Psychotherapy (TFP):
by
Frank Yeomans, M.D., Ph.D.
TFP
is a treatment based on psychoanalytic concepts designed especially
for borderline patients. This twice-per-week individual psychotherapy
has been developed over a period of decades and is described in a
treatment manual. Although it dates back many
years, TFP combines many of
the elements described in the recently published Guidelines for the
Treatment of Borderline Personality issued by the American
Psychiatric
Association.
For example, TFP places special emphasis on the assessment and on
the treatment contract and frame. The setting up of the
contract and frame
has a behavioral quality in that parameters are established to deal
with the likely threats both to the treatment and to the patient's
well-being that may occur in the course of the treatment. The
patient is engaged
as a collaborator in setting up these conditions.
After the behavioral symptoms of borderline pathology are contained
through structure and limit setting, the psychological structure
that is believed to be the core of borderline personality is analyzed
as it
unfolds in the transference [the relation with the therapist as
perceived by the patient]. While TFP emphasizes the role of interpretation
within psychotherapy sessions, it acknowledges the possible role
of
auxiliary
treatments (e.g. for active eating disorders or substance abuse)
and includes pharmacological interventions to address specific
symptoms as needed.
A distinguishing feature of TFP in contrast to many other treatments
for BPD is the belief in a deep psychological structure (structure
of the mind) that
underlies the specific symptoms of BPD. The focus of treatment is on a
fundamental split in the patient's mind that divides perceptions of self and others
into extremes of bad and good. This internal split determines the patient's
way of experiencing self and others and the environment; in brief, it determines
the patient's experience of reality. Since this internal split determines
the nature of the patient's perceptions, it leads to the specific symptoms
of BPD: chaotic interpersonal relations, impulsive self-destructive behaviors,
and so on.
We believe that this split structure of the mind exists as a developmental
phase in all individuals, but that most individuals move on to a more
integrated structure
of the mind in the course of normal development. The internal split occurs
in the earliest years of human development when strong emotional experiences
are
cumulatively internalized in the individual's mind over time and become
established as “object relations dyads”, or templates of particular
types of relationships. These dyads, or templates, combine a specific representation
of the self and of the other linked by an affect, or strong feeling. Different
dyads stemming from different situations represent specific images of the self
and of the other connected by different affects. These dyads are not exact, accurate
representations of historical reality, but may be distorted, since the memories
are encoded in moments of intense affect.
In borderline individuals, these separate dyads do not become integrated
into a unified whole with a more realistic sense of self and others
in the world.
Instead, dyads associated with sharply different affects exist independently
from one another and determine the lack of continuity of the borderline
patient's
experience in life.
The question arises as to why the integration of dyads does not
occur in borderline individuals. TFP proposes a combination of
reasons for
this.
Elements of biologically-determined
temperament combine with environment factors to maintain this split
psychological structure. In over-simplified terms, internal representations
of gratifying
caregivers in relation to a satisfied self are totally split off
from internal representations
of frustrating caregivers in relation to a helpless deprived self.
These opposite images are imbued with intense affects, loving in
association with the first
internal representation, and hateful in association with the second.
While the patient has no conscious awareness of this split internal
world,
his
reactions to events involve a constant flipping back and forth between
the extreme positive
and the negative sides of his mind. This flipping back and forth
creates the subjective instability that determines the symptoms
of BPD: chaos
in interpersonal
relations, emotional lability, black-and-white thinking, anger, and
proneness to lapses in reality testing.
The treatment focuses on the transference [the patient's moment-to-moment
experience of the therapist] because it is believed that the patient lives out
his/her predominant object relations dyads in the transference. Once the treatment
frame is in place, the core task in TFP is to identify these internal object
relations dyads that act as the “lenses” which determine the patient's
experience of the self and the world. It is believed that the information that
unfolds within the patient's relation with the therapist provides the most
direct access to understanding the make-up of the patient's internal world.
A brief summary of the course of treatment is as follows: as the
unintegrated representations of self and other get played out
in the course of the
treatment, the therapist helps the patient understand the reasons – the fears and
anxieties – that support the continued separation of these fragmented senses
of self and other. This understanding is accompanied by the experiencing of strong
affects within the therapeutic relationship. The combination of understanding
and affective experience can lead to the integration of the split-off representations
and the creation of an integrated sense of the patient's identity and experience
of others. This integrated psychological state translates into a decrease in
emotional lability, impulsivity and interpersonal chaos, and the ability to proceed
with effective choices in work and relationships. In other words, our experience
is that the integration of the psychological structure can result in the resolution
and cure of the borderline condition.
About
Dialectical Behavioral Therapy (DBT):
by Cynthia Sanderson, Ph.D.
Within the past 15 years, another, newer psychosocial treatment
termed dialectical behavior therapy (DBT) was developed. Dialectical
Behavior
Therapy (DBT) combines standard cognitive behavioral techniques
with acceptance based strategies, as well as strategies designed
to keep
the therapy balanced
between change and acceptance (dialectical strategies). Marsha
M. Linehan, Ph.D., specifically designed it for treatment of clients
with chronic
suicidality and a diagnosis of Borderline Personality Disorder
(BPD).
More recently, it has been researched and found effective for BPD
and substance abuse, treatment of bulimia, and treatment of elderly
clients
with refractory depression.
Theoretically, DBT hypothesizes that the behaviors characterizing
BPD arise from a transaction between the patient's emotional vulnerability, lack of emotion
modulation skills, and an invalidating environment. The effect of this interaction,
and the key problem in BPD, is thought to be “pervasive emotional dysregulation”.
Most everyone becomes emotionally dysregulated at certain times of their lives,
typically in situations of high intensity; for instance, the death of a close
relative can cause intense grief, falling in love intense joy, being victim of
a crime intensive fear and/or anger. When dysregulated, the person's emotions
are “in the driver's seat”, coloring all he or she thinks,
feels, and does. Patients diagnosed with BPD are different from those without
the diagnosis in quality but not kind; in other words, everyone may get dysregulated
now and then but patients with BPD are dysregulated are pervasively dysregulated – across
time, people, and context. Their dysregulation is characterized by high sensitivity
to stimuli, high intensity arousal, and a slow return to baseline. Further, they
more frequently experience negative emotions, such as shame, fear, sadness, and
anger; baseline is typically dysthymia. In DBT, it is thought that the behaviors
associated with BPD – suicide attempts and self-harm, frantic attempts
to avoid abandonment, chaotic interpersonal relationships, impulsity, etc. – both
result from and are a faulty attempt to respond to severe emotional dysregulation.
In order to comprehensively address the problem behaviors of clients
diagnosed with BPD, DBT uses five modes of treatment that serve
distinctive functions.
These functions/ modes are, briefly: 1) Individual therapy to address
and maintain the patient's motivation for treatment; 2) group skills training to increase
the patient's capacities; 3) brief weekly phone calls to insure generalization
of new skills; 4) therapist consultation team to provide supervision and prevent
burnout; and 5) administrative function to structure the environment so effective
treatment can take place.
Research on DBT, a manualized psychotherapy, has been funded by
the National Institute of Mental Health and the National Institute
of Drug Abuse.
Its use is currently supported by five randomized clinical trials,
conducted by Linehan
at the University of Washington and by scientists at other sites. According
to the guidelines of Division 29 of the American Psychological Association,
it meets
full criteria as a well-established empirically-supported therapy.
STEPPS:
STEPPS is an acronym for Systems Training for
Emotional Predictability and Problem Solving.
The approach of
this treatment is cognitive-behavioral
and based around skills training. BPD is
regarded as a emotional and behavioral regulation disorder,
and
therefore learning
emotion and behavior regulation
skills is the primary goal of treatment.
In addition, professionals
treating the BPD patient, as well as the
patient's family members and close friends
are taught methods of reinforcing and supporting the new emotional and behavioral
regulation skills, reducing the likelihood that the patient will practice “splitting” with
those in their social support system.
Supportive Psychotherapy:
by Ann Appelbaum, M.D.
Supportive
psychotherapy is a broad term describing a type of therapy that emphasizes
consistency,
support from
the
therapist and a hopeful
attitude in order to contain and sustain
the patient through crises periods and
encourage
small gains over time. This type of psychotherapy
can be either
group or individual
and
is
an alternative to transference-focused
psychotherapy (TFP) and dialectical behavioral
therapy (DBT).
In any case, choosing a method of psychotherapeutic
treatment should be based largely on the
needs of the specific
individual. Although
quite different
in their styles, both approaches have proven
to be successful in many borderline patients.
Most borderline
patients
need a psychotherapy that focuses consistently
upon the feelings that underlie their problem
of "thinking in black and
white," experiencing others or themselves as wonderful
at some times and as worthless at other times. Families may
need counseling throughout
the first several years of psychotherapy in order to provide
the emotional support
the patient needs and to avoid harmful interactions with
the patient. Appropriate support may include learning to set
limits with the patient
rather than
give in to threats or unreasonable demands.
Medication
by Judit Gordon-Lendvay, M.D.
Medication
may be needed as part of outpatient treatment. Pharmacological treatments
are often prescribed based
on specific target symptoms
shown by the individual patient. Antidepressant
drugs and mood stabilizers may
be helpful
for depressed and/or labile mood. Antipsychotic
drugs may also be used in low doses
when there are
distortions in thinking
and, at
low
doses, for anxiety.
Patients
with marked mood swings sometimes benefit from certain drugs ordinarily
used to treat epilepsy
like mood
stabilizers. Patients
with severe depression
or eating disorders may benefit from
antidepressant medication. Small
doses of
the neuroleptic
drugs typically used for
schizophrenia
sometimes
help borderline
patients in periods of severe stress.
Lithium is sometimes helpful, and
may make it possible
to use lower doses
of other drugs. Minor
tranquilizers or
sedatives should be considered only
with caution since they are dangerously habit
forming. The
treatment professional
will
be
the best source
of
knowledge on what medications may
or may not benefit the Borderline patient depending
on his or her symptoms and individual needs.
